Healthcare Provider Details

I. General information

NPI: 1962332197
Provider Name (Legal Business Name): CARRIE KELLER BS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/20/2026
Last Update Date: 05/20/2026
Certification Date: 05/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 LANDMARK DR STE 2B
NORMAL IL
61761-6164
US

IV. Provider business mailing address

307 W MULBERRY ST APT 4
BLOOMINGTON IL
61701-2983
US

V. Phone/Fax

Practice location:
  • Phone: 309-808-6802
  • Fax:
Mailing address:
  • Phone: 309-808-6802
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: