Provider Demographics
NPI:1215334479
Name:KEENAN, KATHLEEN ROSE (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:ROSE
Last Name:KEENAN
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 ROBERT T LONGWAY BLVD
Mailing Address - Street 2:SUITE C
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48503-2190
Mailing Address - Country:US
Mailing Address - Phone:810-496-4955
Mailing Address - Fax:
Practice Address - Street 1:2700 ROBERT T LONGWAY BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48503-2190
Practice Address - Country:US
Practice Address - Phone:810-496-4955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-03
Last Update Date:2014-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101001513235Z00000X
OHSP.10968235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist