Provider Demographics
NPI:1295846566
Name:BURNS, KEITH WELLMAN JR (LCSW)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:WELLMAN
Last Name:BURNS
Suffix:JR
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:78 ATLANTIC PL
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-2316
Mailing Address - Country:US
Mailing Address - Phone:207-842-7701
Mailing Address - Fax:207-842-7773
Practice Address - Street 1:474 MAIN STREET
Practice Address - Street 2:
Practice Address - City:SPRINGVALE
Practice Address - State:ME
Practice Address - Zip Code:04083
Practice Address - Country:US
Practice Address - Phone:207-324-1500
Practice Address - Fax:207-490-5263
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2012-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC78201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME245780099Medicaid