Provider Demographics
NPI:1285956755
Name:KEITH, M OUIDA (LCSW)
Entity type:Individual
Prefix:
First Name:M
Middle Name:OUIDA
Last Name:KEITH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:M
Other - Middle Name:OUIDA
Other - Last Name:BREVARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1046 RIDGE AVE SW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30315-1640
Mailing Address - Country:US
Mailing Address - Phone:404-627-1385
Mailing Address - Fax:404-688-2962
Practice Address - Street 1:2685 METROPOLITAN PKWY SW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30315-7900
Practice Address - Country:US
Practice Address - Phone:404-627-1385
Practice Address - Fax:404-688-2962
Is Sole Proprietor?:No
Enumeration Date:2010-02-24
Last Update Date:2010-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW002014104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical