MEDICARE: LAURA KEANON LCSW-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	01142	MD

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	642476	OTHER	MD	MEDICARE PTAN

General Provider Information

NPI Number	:	1063565638
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURA KEANON LCSW-C

Provider Business Mailing Address
First Line	:	2012 HANOVER ST
Second Line	:
City	:	SILVER SPRING
State	:	MD
Zip	:	20910-2105
Country	:	US
Telephone Number	:	301-585-8075
Fax Number	:

Provider Business Practice Location Address
First Line	:	2012 HANOVER ST
Second Line	:
City	:	SILVER SPRING
State	:	MD
Zip	:	20910-2105
Country	:	US
Telephone Number	:	301-585-8075
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/18/2007
Last Update Date	:	02/07/2014

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