Provider Demographics
NPI:1023144417
Name:KEEGAN, DIANNE (PT)
Entity type:Individual
Prefix:MS
First Name:DIANNE
Middle Name:
Last Name:KEEGAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 SUFFOLK AVENUE
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11717-4304
Mailing Address - Country:US
Mailing Address - Phone:631-434-3232
Mailing Address - Fax:631-265-2559
Practice Address - Street 1:620 SUFFOLK AVE
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:NY
Practice Address - Zip Code:11717-4304
Practice Address - Country:US
Practice Address - Phone:631-434-3232
Practice Address - Fax:631-265-2559
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002479225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY4619610OtherAETNA
NYQ51712OtherBLUE CROSS
NYQ51712Medicare PIN