Provider Demographics
NPI:1255385290
Name:KEDDIE, STELLA GRACE (MSW LCSW)
Entity type:Individual
Prefix:MRS
First Name:STELLA
Middle Name:GRACE
Last Name:KEDDIE
Suffix:
Gender:F
Credentials:MSW LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37 MCMURRAY ROAD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15241
Mailing Address - Country:US
Mailing Address - Phone:712-854-3602
Mailing Address - Fax:412-854-2121
Practice Address - Street 1:37 MCMURRAY ROAD
Practice Address - Street 2:SUITE 102
Practice Address - City:PITTSBURG
Practice Address - State:PA
Practice Address - Zip Code:15241
Practice Address - Country:US
Practice Address - Phone:412-854-3602
Practice Address - Fax:412-854-2121
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0128291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
123807OtherVALUE OPTIONS
296639OtherMHN
895522OtherHIGHMARK
0005149Medicare ID - Type Unspecified