Provider Demographics
NPI:1932387883
Name:KESECKER, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:KESECKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 E MARKET ST
Mailing Address - Street 2:
Mailing Address - City:HARRISONBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22801-4227
Mailing Address - Country:US
Mailing Address - Phone:540-433-8830
Mailing Address - Fax:540-433-8830
Practice Address - Street 1:202 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:LEWISBURG
Practice Address - State:WV
Practice Address - Zip Code:24901-1108
Practice Address - Country:US
Practice Address - Phone:304-647-6483
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-02
Last Update Date:2008-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV22051103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool