Healthcare Provider Details

I. General information

NPI: 1316303654
Provider Name (Legal Business Name): KEITH LAKES LPCC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/31/2015
Last Update Date: 12/31/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11623 HIGHWAY 3630
ANNVILLE KY
40402
US

IV. Provider business mailing address

11623 HIGHWAY 3630
ANNVILLE KY
40402-8182
US

V. Phone/Fax

Practice location:
  • Phone: 606-364-3640
  • Fax: 606-364-2534
Mailing address:
  • Phone: 606-364-3640
  • Fax: 606-364-2534

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number0224
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: