MEDICARE: MAXINE LYNN KELLER LCADC, CADC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	ADCADC00220812	KY
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	166100	KY

General Provider Information

NPI Number	:	1831555853
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MAXINE LYNN KELLER LCADC, CADC

Provider Business Mailing Address
First Line	:	102 PASCO ST
Second Line	:
City	:	BEREA
State	:	KY
Zip	:	40403-1529
Country	:	US
Telephone Number	:	859-200-3894
Fax Number	:

Provider Business Practice Location Address
First Line	:	102 PASCO ST
Second Line	:
City	:	BEREA
State	:	KY
Zip	:	40403-1529
Country	:	US
Telephone Number	:	859-200-3894
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/06/2016
Last Update Date	:	08/04/2017

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