Provider Demographics
NPI:1316056674
Name:KEENE, ALICE (LPC)
Entity type:Individual
Prefix:
First Name:ALICE
Middle Name:
Last Name:KEENE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:ALICE
Other - Middle Name:MAE
Other - Last Name:KEENE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMHC, LPC
Mailing Address - Street 1:712 SARA JANE LN
Mailing Address - Street 2:
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32952-4944
Mailing Address - Country:US
Mailing Address - Phone:321-208-5583
Mailing Address - Fax:
Practice Address - Street 1:1037 PATHFINDER WAY
Practice Address - Street 2:INTERVENTION SERVICES SUITE 130
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955
Practice Address - Country:US
Practice Address - Phone:321-639-1224
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2012-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL7610101YM0800X
NC4821101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC140EGOtherNVML BCBSNC GRP # 015HF
NC6102594Medicaid