Provider Demographics
NPI:1861535254
Name:KEOHANE, MICHAEL L (LCSW)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:L
Last Name:KEOHANE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 CUMBERLAND ST
Mailing Address - Street 2:4TH FLOOR, EXECUTIVE PLAZA
Mailing Address - City:BRISTOL
Mailing Address - State:VA
Mailing Address - Zip Code:24201-4324
Mailing Address - Country:US
Mailing Address - Phone:276-645-4758
Mailing Address - Fax:276-669-9093
Practice Address - Street 1:27018 LEE HWY
Practice Address - Street 2:
Practice Address - City:ABINGDON
Practice Address - State:VA
Practice Address - Zip Code:24211-7512
Practice Address - Country:US
Practice Address - Phone:276-628-8513
Practice Address - Fax:276-628-2046
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040063811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical