Healthcare Provider Details

I. General information

NPI: 1134721251
Provider Name (Legal Business Name): LACEY KELLER CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2020
Last Update Date: 11/19/2020
Certification Date: 11/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2280 US 29
NEWNAN GA
30265
US

IV. Provider business mailing address

2280 US 29
NEWNAN GA
30265
US

V. Phone/Fax

Practice location:
  • Phone: 770-683-6833
  • Fax:
Mailing address:
  • Phone: 678-588-8687
  • Fax: 855-232-8604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSLP009612
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: