Provider Demographics
NPI:1417954686
Name:AUSTIN, KEITHA MAUREEN (LCSW, BCD)
Entity Type:Individual
Prefix:MS
First Name:KEITHA
Middle Name:MAUREEN
Last Name:AUSTIN
Suffix:
Gender:F
Credentials:LCSW, BCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 KEITH RD
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-1109
Mailing Address - Country:US
Mailing Address - Phone:757-223-1020
Mailing Address - Fax:
Practice Address - Street 1:12725 MCMANUS BLVD
Practice Address - Street 2:SUITE 2G
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23602-4402
Practice Address - Country:US
Practice Address - Phone:757-874-1676
Practice Address - Fax:757-874-2226
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-03
Last Update Date:2008-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040025551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1417954686Medicaid
VA1417954686Medicaid