Provider Demographics
NPI:1760453583
Name:MCKEAN, MARY M (LISW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:M
Last Name:MCKEAN
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 817
Mailing Address - Street 2:
Mailing Address - City:WEST LIBERTY
Mailing Address - State:OH
Mailing Address - Zip Code:43357-0817
Mailing Address - Country:US
Mailing Address - Phone:937-644-9192
Mailing Address - Fax:937-644-3426
Practice Address - Street 1:715 S PLUM ST
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43040
Practice Address - Country:US
Practice Address - Phone:937-644-9192
Practice Address - Fax:937-644-3426
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI00095721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHMCSW30251Medicare ID - Type Unspecified