Provider Demographics
NPI:1063565638
Name:KEANON, LAURA (LCSW-C)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:KEANON
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:
Other - Last Name:BOLDRICK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW-C
Mailing Address - Street 1:2012 HANOVER ST
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20910-2105
Mailing Address - Country:US
Mailing Address - Phone:301-585-8075
Mailing Address - Fax:
Practice Address - Street 1:2012 HANOVER ST
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20910-2105
Practice Address - Country:US
Practice Address - Phone:301-585-8075
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2014-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD011421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD642476OtherMEDICARE PTAN