Provider Demographics
NPI:1568425635
Name:FENDER, KEITH EDWARD (PHD, LCSW)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:EDWARD
Last Name:FENDER
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 1:519 2ND ST
Mailing Address - Street 2:
Mailing Address - City:RADFORD
Mailing Address - State:VA
Mailing Address - Zip Code:24141-1403
Mailing Address - Country:US
Mailing Address - Phone:540-639-9040
Mailing Address - Fax:540-639-9040
Practice Address - Street 1:519 2ND ST
Practice Address - Street 2:
Practice Address - City:RADFORD
Practice Address - State:VA
Practice Address - Zip Code:24141-1403
Practice Address - Country:US
Practice Address - Phone:540-639-9040
Practice Address - Fax:540-639-9040
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040044051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA8927286Medicaid
VA337626OtherTRIGON/ANTHEM BLUE CROSS
VA8927286Medicaid