Provider Demographics
NPI:1013049139
Name:KEANE, KEVIN (LPC, NCC)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:
Last Name:KEANE
Suffix:
Gender:M
Credentials:LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 BRIDLE PATH RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06488-2437
Mailing Address - Country:US
Mailing Address - Phone:203-264-3096
Mailing Address - Fax:203-264-3096
Practice Address - Street 1:150 BRIDLE PATH RD
Practice Address - Street 2:
Practice Address - City:SOUTHBURY
Practice Address - State:CT
Practice Address - Zip Code:06488-2437
Practice Address - Country:US
Practice Address - Phone:203-264-3096
Practice Address - Fax:203-264-3096
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001458101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional