Provider Demographics
NPI:1497214803
Name:BAUER, KEITH ALAN (PHD, LCSW)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:ALAN
Last Name:BAUER
Suffix:
Gender:M
Credentials:PHD, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 UNIVERSITY CITY BLVD
Mailing Address - Street 2:
Mailing Address - City:BLACKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24060-2706
Mailing Address - Country:US
Mailing Address - Phone:540-961-8300
Mailing Address - Fax:540-961-8465
Practice Address - Street 1:327 N WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:PULASKI
Practice Address - State:VA
Practice Address - Zip Code:24301-5009
Practice Address - Country:US
Practice Address - Phone:540-994-5023
Practice Address - Fax:540-994-5028
Is Sole Proprietor?:No
Enumeration Date:2019-03-15
Last Update Date:2019-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040109821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical