Provider Demographics
NPI:1013550250
Name:KEENE, KRISTEN A (LPC)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:A
Last Name:KEENE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 F ST STE 202
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31520-6788
Mailing Address - Country:US
Mailing Address - Phone:912-319-4041
Mailing Address - Fax:
Practice Address - Street 1:127 F ST STE 202
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-6788
Practice Address - Country:US
Practice Address - Phone:912-319-4041
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-21
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC011189101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA09637169OtherAMERIGROUP
GA003229861AMedicaid