1679900765 NPI number — JOHN KEANE IV LMSW,BA

Table of content: JOHN KEANE IV LMSW,BA (NPI 1679900765)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679900765 NPI number — JOHN KEANE IV LMSW,BA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KEANE
Provider First Name:
JOHN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
IV
Provider Credential Text:
LMSW,BA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1679900765
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/02/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
141 E MAIN ST
Provider Second Line Business Mailing Address:
4TH FLOOR ADMINISTRATION
Provider Business Mailing Address City Name:
WATERBURY
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06702-2310
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-574-9000
Provider Business Mailing Address Fax Number:
203-574-9006

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
402 E MAIN ST
Provider Second Line Business Practice Location Address:
WATERBURY OP ADULT SERVICES
Provider Business Practice Location Address City Name:
WATERBURY
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06702-1701
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-755-1143
Provider Business Practice Location Address Fax Number:
203-755-1447
Provider Enumeration Date:
10/03/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 104100000X , with the licence number: 2166 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: PENDING . This is a "AETNA BEHAVIORAL HEALTH" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 008064408 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 060669107 . This is a "OPTUM BEHAVIORAL HEALTH/UBH WELLMORE GRP/FACILITY" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 060669107 . This is a "HEALTHYCT WELLMORE GRP/FACILITY" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: NOT ELIGIBLE . This is a "MHN TRICARE NORTH" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 060669107 . This is a "UBH-CONNECTICARE WELLMORE GRP/FACILITY" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 060669107 . This is a "ANTHEM BEHAVIORAL HEALTH WELLMORE GRP/FACILITY" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: PENDING . This is a "CIGNA BEHAVIORAL HEALTH" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 13671836 . This is a "CAQH" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: D339123 WATERBURY . This is a "BEACON HEALTH STRATEGIES" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: NOT ELIGIBLE . This is a "MHN MANAGED HEALTH NETWORK" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 060669107 . This is a "UBH-OXFORD FREEDOM/LIBERTY" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 060669107 . This is a "UBH-UNITED HEALTHCARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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