=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881940120
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MRS. KIMBERLY KEEGAN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/24/2012
-----------------------------------------------------
Last Update Date | 02/04/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 340 BRYANT RD
-----------------------------------------------------
City | WATERTOWN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06795-1119
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-274-6070
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 340 BRYANT RD
-----------------------------------------------------
City | WATERTOWN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06795-1119
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-274-6070
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 1840
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------