Individual
JOHN KEANE IV
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
LMSW,BA
Contact information
Practice address
402 E MAIN ST, WATERBURY OP ADULT SERVICES, WATERBURY, CT 06702-1701
(203) 755-1143
(203) 755-1447
Mailing address
141 E MAIN ST, 4TH FLOOR ADMINISTRATION, WATERBURY, CT 06702-2310
(203) 574-9000
(203) 574-9006
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
—
—
104100000X
Social Worker
2166
CT
1041C0700X
Clinical Social Worker
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
008064408
—
CT
01
—
060669107
OPTUM BEHAVIORAL HEALTH/UBH WELLMORE GRP/FACILITY
CT
01
—
13671836
CAQH
CT
01
—
D339123 WATERBURY
BEACON HEALTH STRATEGIES
CT
01
—
NOT ELIGIBLE
MHN TRICARE NORTH
CT
01
—
PENDING
AETNA BEHAVIORAL HEALTH
CT
Enumeration date
10/03/2013
Last updated
06/02/2020
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