Provider Demographics
NPI:1043437288
Name:KEANE, MARY THERESA (LCSW-C)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:THERESA
Last Name:KEANE
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:
Other - First Name:M.
Other - Middle Name:THERESA
Other - Last Name:KEANE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW-C
Mailing Address - Street 1:6148 WAITING SPG
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21045-4044
Mailing Address - Country:US
Mailing Address - Phone:410-730-2889
Mailing Address - Fax:
Practice Address - Street 1:9810 PATUXENT WOODS DR STE C
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21046-1595
Practice Address - Country:US
Practice Address - Phone:410-290-6432
Practice Address - Fax:410-290-6604
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD059241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDR980-0003OtherBCBS NATL CAPITOL AREA
MD718102-01OtherCAREFIRST BCBSOF MD