Healthcare Provider Details

I. General information

NPI: 1699850420
Provider Name (Legal Business Name): MARY KATHLEEN KEENAN LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10470 ARMSTRONG ST
FAIRFAX VA
22030-3648
US

IV. Provider business mailing address

11518 CLARA BARTON DR
FAIRFAX STATION VA
22039-1334
US

V. Phone/Fax

Practice location:
  • Phone: 703-385-7575
  • Fax: 703-385-7578
Mailing address:
  • Phone: 703-250-4302
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701003305
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: