Healthcare Provider Details

I. General information

NPI: 1417954686
Provider Name (Legal Business Name): KEITHA MAUREEN AUSTIN LCSW, BCD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2005
Last Update Date: 01/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12725 MCMANUS BLVD SUITE 2G
NEWPORT NEWS VA
23602-4402
US

IV. Provider business mailing address

121 KEITH RD
NEWPORT NEWS VA
23606-1109
US

V. Phone/Fax

Practice location:
  • Phone: 757-874-1676
  • Fax: 757-874-2226
Mailing address:
  • Phone: 757-223-1020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904002555
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: