Provider Demographics
NPI:1457558553
Name:KEENEY, MIKAYLA ERIN (LCSW)
Entity Type:Individual
Prefix:
First Name:MIKAYLA
Middle Name:ERIN
Last Name:KEENEY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TORRINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06790-5330
Mailing Address - Country:US
Mailing Address - Phone:860-689-3155
Mailing Address - Fax:860-738-8041
Practice Address - Street 1:79 MAIN ST
Practice Address - Street 2:
Practice Address - City:TORRINGTON
Practice Address - State:CT
Practice Address - Zip Code:06790-5330
Practice Address - Country:US
Practice Address - Phone:860-689-3155
Practice Address - Fax:860-738-8041
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-02
Last Update Date:2016-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0071361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT007136OtherLICENSE