Basic Information
| Provider Information | |||||||||
| NPI: | 1669972493 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KEEN | ||||||||
| FirstName: | CORI | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MA, BCBA | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3500 DEPAUW BLVD STE 3070 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462686135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8553240885 | ||||||||
| FaxNumber: | 3175208200 | ||||||||
| Practice Location | |||||||||
| Address1: | 6925 PARKDALE PL | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462544673 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175974553 | ||||||||
| FaxNumber: | 3175208200 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/19/2018 | ||||||||
| LastUpdateDate: | 07/25/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 07/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1-21-50509 | IN | Y | Behavioral Health & Social Service Providers | Behavioral Analyst | 106S00000X | N |
ID Information
| ID | Type | State | Issuer | Description | 1-21-50509 | 01 | IN | BCBA SUPERVISORY CERTIFICATION | OTHER | 1-21-50509 | 01 | IN | BCBA CERTIFICATION | OTHER |