Provider Demographics
NPI:1306977277
Name:KEITH, MARY M (AU D)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:M
Last Name:KEITH
Suffix:
Gender:F
Credentials:AU D
Other - Prefix:DR
Other - First Name:MARY
Other - Middle Name:M
Other - Last Name:CODY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AUD
Mailing Address - Street 1:1324 BELMONT ST
Mailing Address - Street 2:SUITE 204
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-4435
Mailing Address - Country:US
Mailing Address - Phone:508-559-9200
Mailing Address - Fax:508-559-0027
Practice Address - Street 1:1324 BELMONT ST
Practice Address - Street 2:SUITE 204
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-4435
Practice Address - Country:US
Practice Address - Phone:508-559-9200
Practice Address - Fax:508-559-0027
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2010-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA140231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAAD0001OtherBCBS PROVIDER NUMBER