=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609654011
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MALCOLM KEETON LPC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/18/2023
-----------------------------------------------------
Last Update Date | 09/18/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1909 HUGUENOT RD STE 202
-----------------------------------------------------
City | NORTH CHESTERFIELD
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23235-4314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 795-280-4350
-----------------------------------------------------
Fax | 866-330-1467
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4125 RALPH RD
-----------------------------------------------------
City | SOUTH CHESTERFIELD
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23803-2524
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 0701012883
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------