Provider Demographics
NPI:1740980234
Name:KEOUGH, CAROLYN BURDETT (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:BURDETT
Last Name:KEOUGH
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8954 ANTIGUA DR
Mailing Address - Street 2:
Mailing Address - City:SEMINOLE
Mailing Address - State:FL
Mailing Address - Zip Code:33777-2144
Mailing Address - Country:US
Mailing Address - Phone:727-421-8551
Mailing Address - Fax:
Practice Address - Street 1:6150 150TH AVE N
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33760-2138
Practice Address - Country:US
Practice Address - Phone:727-422-0352
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-06
Last Update Date:2025-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11024878363LP0808X, 324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL122759400Medicaid