Provider Demographics
NPI:1477536910
Name:KEITH, MICHAEL GLEN (LCSW)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:GLEN
Last Name:KEITH
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6538 ORLAND ST
Mailing Address - Street 2:
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22043-1815
Mailing Address - Country:US
Mailing Address - Phone:703-536-1736
Mailing Address - Fax:703-536-7610
Practice Address - Street 1:6062 ARLINGTON BLVD
Practice Address - Street 2:
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22044-2943
Practice Address - Country:US
Practice Address - Phone:703-536-1736
Practice Address - Fax:703-536-7610
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-29
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040037321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical