Healthcare Provider Details

I. General information

NPI: 1679230643
Provider Name (Legal Business Name): HEATHER ANN KEANE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/24/2021
Last Update Date: 03/23/2026
Certification Date: 03/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 OLD DIXIE HWY FL 32084
ST AUGUSTINE FL
32084-4190
US

IV. Provider business mailing address

1400 OLD DIXIE HWY FL 32084
ST AUGUSTINE FL
32084-4190
US

V. Phone/Fax

Practice location:
  • Phone: 904-829-2273
  • Fax:
Mailing address:
  • Phone: 904-829-2273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH27405
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: