Provider Demographics
NPI:1578385563
Name:KEANE, GRACE ELIZABETH (RD, LD)
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:ELIZABETH
Last Name:KEANE
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:575 ARLINGTON LN
Mailing Address - Street 2:
Mailing Address - City:SOUTH ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60177-2866
Mailing Address - Country:US
Mailing Address - Phone:847-804-6032
Mailing Address - Fax:
Practice Address - Street 1:621 S NEW BALLAS RD STE 2007B
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8265
Practice Address - Country:US
Practice Address - Phone:314-991-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-30
Last Update Date:2024-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2024041895133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered