Basic Information
| Provider Information | |||||||||
| NPI: | 1811191414 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KEANE | ||||||||
| FirstName: | THERESA | ||||||||
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| Credential: | PH.D., NPP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 97 GRACE WAY | ||||||||
| Address2: | |||||||||
| City: | OLIVEBRIDGE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 124615236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9174533684 | ||||||||
| FaxNumber: | 9174533684 | ||||||||
| Practice Location | |||||||||
| Address1: | 7750 E BROADWAY BLVD STE A100 | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857103901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5203271529 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2007 | ||||||||
| LastUpdateDate: | 08/04/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 011974-1 | NY | N | Behavioral Health & Social Service Providers | Psychologist | Clinical | 363LP0808X | F401198 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.