Provider Demographics
NPI:1154664670
Name:KEOGH, RYAN (PMHNP-BC)
Entity type:Individual
Prefix:MR
First Name:RYAN
Middle Name:
Last Name:KEOGH
Suffix:
Gender:M
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 1:55 FRUIT ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-2696
Mailing Address - Country:US
Mailing Address - Phone:617-724-9144
Mailing Address - Fax:
Practice Address - Street 1:55 FRUIT ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2696
Practice Address - Country:US
Practice Address - Phone:617-724-9110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-03
Last Update Date:2024-12-02
Deactivation Date:2021-09-20
Deactivation Code:
Reactivation Date:2021-10-20
Provider Licenses
StateLicense IDTaxonomies
MARN2331463363LP0808X, 363LP0808X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst