Provider Demographics
NPI:1932378619
Name:KEENEY, RUSSELL (LPC)
Entity Type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:
Last Name:KEENEY
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:MR
Other - First Name:RUSS
Other - Middle Name:
Other - Last Name:KEENEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPC
Mailing Address - Street 1:PO BOX 550842
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28055-0842
Mailing Address - Country:US
Mailing Address - Phone:704-706-4141
Mailing Address - Fax:
Practice Address - Street 1:146 E MCLELLAND AVE
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28115-2611
Practice Address - Country:US
Practice Address - Phone:704-291-4173
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-26
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5521101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6103903Medicaid