Provider Demographics
NPI:1003526450
Name:KEOUGH, DANIELLE (PTA)
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:
Last Name:KEOUGH
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 STADDEN ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02907-3548
Mailing Address - Country:US
Mailing Address - Phone:401-447-2310
Mailing Address - Fax:
Practice Address - Street 1:1139 MAIN AVE
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02886-1940
Practice Address - Country:US
Practice Address - Phone:401-739-6600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-28
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPTA00821225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant