Provider Demographics
NPI:1588376891
Name:FAIRFAX, KEANA (MSW, LCSW)
Entity type:Individual
Prefix:MRS
First Name:KEANA
Middle Name:
Last Name:FAIRFAX
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:MS
Other - First Name:KEANA
Other - Middle Name:
Other - Last Name:REED
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW, LCSW
Mailing Address - Street 1:914 EDGEMOOR RD
Mailing Address - Street 2:
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08034-3940
Mailing Address - Country:US
Mailing Address - Phone:609-920-3848
Mailing Address - Fax:
Practice Address - Street 1:11 W ORMOND AVE STE 100A
Practice Address - Street 2:
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08002-3051
Practice Address - Country:US
Practice Address - Phone:609-920-3848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-19
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC060000001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical