Healthcare Provider Details

I. General information

NPI: 1285085779
Provider Name (Legal Business Name): LARRY KELLER LSATP, LCAS, CAADC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2016
Last Update Date: 07/21/2020
Certification Date: 07/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1555 MEADOWVIEW DR STE 5
DANVILLE VA
24541
US

IV. Provider business mailing address

8932 KENTUCK RD
RINGGOLD VA
24586-5426
US

V. Phone/Fax

Practice location:
  • Phone: 434-685-1570
  • Fax: 434-685-1477
Mailing address:
  • Phone: 434-334-6508
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number0718000420
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0710103300
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1436
License Number StateVA
# 4
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCAS-234233
License Number StateNC
# 5
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCSAC20095
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: