=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912389909
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KYLE KELLER LPC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/25/2015
-----------------------------------------------------
Last Update Date | 06/25/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 289 INDEPENDENCE BLVD STE 312
-----------------------------------------------------
City | VIRGINIA BEACH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23462-5493
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-385-0684
-----------------------------------------------------
Fax | 757-493-5456
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 289 INDEPENDENCE BLVD STE 312
-----------------------------------------------------
City | VIRGINIA BEACH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23462-5493
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-385-0684
-----------------------------------------------------
Fax | 757-493-5456
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 0701006101
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------