Provider Demographics
NPI:1659129187
Name:KEAVENEY, KRISTEN MARIE
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:MARIE
Last Name:KEAVENEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:MARIE
Other - Last Name:FLADE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LBS
Mailing Address - Street 1:12418 ACADEMY RD
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19154-1929
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:170 PHEASANT RUN STE 110
Practice Address - Street 2:
Practice Address - City:NEWTOWN
Practice Address - State:PA
Practice Address - Zip Code:18940-1877
Practice Address - Country:US
Practice Address - Phone:215-579-0670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-09
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABH007087103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst