Provider Demographics
NPI:1699840793
Name:KEY, MARY RUDISILL (LCSW, LCAS)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:RUDISILL
Last Name:KEY
Suffix:
Gender:F
Credentials:LCSW, LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8009 NETHERLANDS DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27606-9655
Mailing Address - Country:US
Mailing Address - Phone:919-744-4089
Mailing Address - Fax:
Practice Address - Street 1:1140 KILDAIRE FARM RD
Practice Address - Street 2:SUITE 200 ROOM 9
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27511-4562
Practice Address - Country:US
Practice Address - Phone:919-744-4089
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-22
Last Update Date:2015-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1063101YA0400X
NCC0061891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6111890Medicaid