Provider Demographics
NPI:1902082522
Name:KEANE, ANNASTATIA K (PT)
Entity Type:Individual
Prefix:MRS
First Name:ANNASTATIA
Middle Name:K
Last Name:KEANE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MRS
Other - First Name:ANNASTATIA
Other - Middle Name:K
Other - Last Name:BLAGG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT
Mailing Address - Street 1:411 WAVERLEY OAKS ROAD
Mailing Address - Street 2:BUILDING #3, SUITE 305
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02452
Mailing Address - Country:US
Mailing Address - Phone:781-894-6564
Mailing Address - Fax:781-893-5938
Practice Address - Street 1:411 WAVERLEY OAKS RD
Practice Address - Street 2:BUILDING #3, SUITE 305
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02452-8448
Practice Address - Country:US
Practice Address - Phone:781-894-6564
Practice Address - Fax:781-893-5938
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-14
Last Update Date:2008-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA133852251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics