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General NPI Number Information
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NPI Number | 1083136683
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Entity Type | Organization
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Legal Business Name | KEEGAN BAKER, LCSW, PLLC
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Dates
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Enumeration Date | 07/14/2017
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Last Update Date | 07/14/2017
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Provider Practice Location Address
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Address Line | 267 E MAIN ST
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City | SMITHTOWN
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State | NY
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Zip | 11787-2874
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Country | US
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Telephone | 631-833-5677
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Fax |
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Provider Business Mailing Address
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Address Line | 3 SETALCOTT PL
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City | SETAUKET
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State | NY
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Zip | 11733-1315
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Country | US
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Telephone | 631-833-5677
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Fax |
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Authorized Official
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Title or Position | CLINICAL SOCIAL WORKER
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Name | MR. RAINE KEEGAN BAKER
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Credential | LCSW
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Telephone | 631-833-5677
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 085486
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License Number State | NY
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