Provider Demographics
NPI:1912034133
Name:KEANEY, LAUREN WALLACE
Entity Type:Individual
Prefix:MS
First Name:LAUREN
Middle Name:WALLACE
Last Name:KEANEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6300
Mailing Address - Street 2:
Mailing Address - City:CRESTLINE
Mailing Address - State:CA
Mailing Address - Zip Code:92325-6300
Mailing Address - Country:US
Mailing Address - Phone:909-336-3330
Mailing Address - Fax:
Practice Address - Street 1:340 CA HWY 138
Practice Address - Street 2:
Practice Address - City:CRESTLINE
Practice Address - State:CA
Practice Address - Zip Code:92325-6300
Practice Address - Country:US
Practice Address - Phone:909-336-3330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool