MEDICARE: MR. MICHAEL GLEN KEITH LCSW

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	0904003732	VA

General Provider Information

NPI Number	:	1477536910
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MICHAEL GLEN KEITH LCSW

Provider Business Mailing Address
First Line	:	6538 ORLAND ST
Second Line	:
City	:	FALLS CHURCH
State	:	VA
Zip	:	22043-1815
Country	:	US
Telephone Number	:	703-536-1736
Fax Number	:	703-536-7610

Provider Business Practice Location Address
First Line	:	6062 ARLINGTON BLVD
Second Line	:
City	:	FALLS CHURCH
State	:	VA
Zip	:	22044-2943
Country	:	US
Telephone Number	:	703-536-1736
Fax Number	:	703-536-7610

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

Provider Enumeration Date	:	11/29/2005
Last Update Date	:	02/04/2014

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