Provider Demographics
NPI:1194984609
Name:KEAVENEY, LISA
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:KEAVENEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57A OLD MARLBORO RD
Mailing Address - Street 2:
Mailing Address - City:MAYNARD
Mailing Address - State:MA
Mailing Address - Zip Code:01754-2147
Mailing Address - Country:US
Mailing Address - Phone:781-270-0222
Mailing Address - Fax:
Practice Address - Street 1:3 BURLINGTON WOODS
Practice Address - Street 2:SUITE 304
Practice Address - City:BURLINGTON
Practice Address - State:MA
Practice Address - Zip Code:01803-4514
Practice Address - Country:US
Practice Address - Phone:781-270-0222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-09
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA260225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA260OtherLICENSE