Provider Demographics
NPI:1023412699
Name:KERANEN, RENEE M (MSW)
Entity type:Individual
Prefix:
First Name:RENEE
Middle Name:M
Last Name:KERANEN
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53074-1813
Mailing Address - Country:US
Mailing Address - Phone:262-284-8133
Mailing Address - Fax:262-284-8104
Practice Address - Street 1:121 W MAIN ST
Practice Address - Street 2:
Practice Address - City:PORT WASHINGTON
Practice Address - State:WI
Practice Address - Zip Code:53074-1813
Practice Address - Country:US
Practice Address - Phone:262-284-8133
Practice Address - Fax:262-284-8104
Is Sole Proprietor?:No
Enumeration Date:2014-10-10
Last Update Date:2015-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7713-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
K400202255OtherMEDICARE PTAN
WI7713-123OtherLICENSE