Provider Demographics
NPI:1972308591
Name:KEFFERSTAN, MARY
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:KEFFERSTAN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:322 KENMORE ST
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-3218
Mailing Address - Country:US
Mailing Address - Phone:304-290-7042
Mailing Address - Fax:
Practice Address - Street 1:322 KENMORE ST
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505-3218
Practice Address - Country:US
Practice Address - Phone:304-290-7042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-17
Last Update Date:2025-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2943101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health