Healthcare Provider Details

I. General information

NPI: 1437174067
Provider Name (Legal Business Name): REBECCA WOLFE KELLER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 02/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

576 JEFFERSON AVE
FORT EUSTIS VA
23604-1373
US

IV. Provider business mailing address

576 JEFFERSON AVE
FORT EUSTIS VA
23604-1373
US

V. Phone/Fax

Practice location:
  • Phone: 757-314-7500
  • Fax: 757-314-7854
Mailing address:
  • Phone: 757-314-7500
  • Fax: 757-314-7854

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904003037
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: