Provider Demographics
NPI:1952052128
Name:SMART, KEENAN MATTHEW (LPCC)
Entity Type:Individual
Prefix:
First Name:KEENAN
Middle Name:MATTHEW
Last Name:SMART
Suffix:
Gender:M
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:551 WARWICK ST
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55116-1539
Mailing Address - Country:US
Mailing Address - Phone:612-910-3065
Mailing Address - Fax:
Practice Address - Street 1:2724 UNIVERSITY AVE SE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55414-3210
Practice Address - Country:US
Practice Address - Phone:612-299-1090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-10
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3147101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health