Provider Demographics
NPI:1285085779
Name:KELLER, LARRY (LSATP, LCAS, CAADC)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:
Last Name:KELLER
Suffix:
Gender:M
Credentials:LSATP, LCAS, CAADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8932 KENTUCK RD
Mailing Address - Street 2:
Mailing Address - City:RINGGOLD
Mailing Address - State:VA
Mailing Address - Zip Code:24586-5426
Mailing Address - Country:US
Mailing Address - Phone:434-334-6508
Mailing Address - Fax:
Practice Address - Street 1:1555 MEADOWVIEW DR STE 5
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24541
Practice Address - Country:US
Practice Address - Phone:434-685-1570
Practice Address - Fax:434-685-1477
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-25
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0718000420101Y00000X
VA0710103300101YA0400X
VA1436101YA0400X
NCLCAS-234233101YA0400X
NCCSAC20095101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor