Provider Demographics
NPI:1184777211
Name:MCKEOWN, RICHARD JAMES (LICSW, LADCI)
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:JAMES
Last Name:MCKEOWN
Suffix:
Gender:M
Credentials:LICSW, LADCI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 GLENDALE RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:MA
Mailing Address - Zip Code:01073-9445
Mailing Address - Country:US
Mailing Address - Phone:413-658-5245
Mailing Address - Fax:
Practice Address - Street 1:39 GLENDALE RD
Practice Address - Street 2:
Practice Address - City:SOUTHAMPTON
Practice Address - State:MA
Practice Address - Zip Code:01073-9445
Practice Address - Country:US
Practice Address - Phone:413-658-5245
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-20
Last Update Date:2015-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10166021041C0700X
MA758101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAPO4769OtherBCBS PROVIDER NUMBER
MAPO4769-80Medicare ID - Type UnspecifiedMA MEDICARE PROVIDER NUMB