Provider Demographics
NPI:1639552508
Name:KEREDA, MARY (MA BSL)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:KEREDA
Suffix:
Gender:F
Credentials:MA BSL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 JEFFORDS CT
Mailing Address - Street 2:
Mailing Address - City:PHOENIXVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19460-2842
Mailing Address - Country:US
Mailing Address - Phone:718-414-5603
Mailing Address - Fax:
Practice Address - Street 1:131 JEFFORDS CT
Practice Address - Street 2:
Practice Address - City:PHOENIXVILLE
Practice Address - State:PA
Practice Address - Zip Code:19460-2842
Practice Address - Country:US
Practice Address - Phone:718-414-5603
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-09
Last Update Date:2015-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABH001389103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
PABH001389OtherBUREAU OF PROFESSIONAL AND OCCCUPATIONAL AFFAIRS