Provider Demographics
NPI:1013296102
Name:MCAULIFFE, KENNETH
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:MCAULIFFE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9475 LOTTSFORD RD
Mailing Address - Street 2:SUITE 250
Mailing Address - City:LARGO
Mailing Address - State:MD
Mailing Address - Zip Code:20774-5357
Mailing Address - Country:US
Mailing Address - Phone:301-636-6504
Mailing Address - Fax:
Practice Address - Street 1:9475 LOTTSFORD RD
Practice Address - Street 2:SUITE 250
Practice Address - City:LARGO
Practice Address - State:MD
Practice Address - Zip Code:20774-5357
Practice Address - Country:US
Practice Address - Phone:301-636-6504
Practice Address - Fax:301-636-6509
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-08
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD14555104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD14555OtherMARYLAND SOCIAL WORK LICENSE NUMBER