Provider Demographics
NPI:1841022944
Name:KEETLEY, CAMERON CASSILY
Entity type:Individual
Prefix:
First Name:CAMERON
Middle Name:CASSILY
Last Name:KEETLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 TOME HWY
Mailing Address - Street 2:
Mailing Address - City:PORT DEPOSIT
Mailing Address - State:MD
Mailing Address - Zip Code:21904-1720
Mailing Address - Country:US
Mailing Address - Phone:443-693-2822
Mailing Address - Fax:
Practice Address - Street 1:301 TOME HWY
Practice Address - Street 2:
Practice Address - City:PORT DEPOSIT
Practice Address - State:MD
Practice Address - Zip Code:21904-1720
Practice Address - Country:US
Practice Address - Phone:443-693-2822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-16
Last Update Date:2024-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD28890101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health