Provider Demographics
NPI:1003160219
Name:KELLER, TRACIE LYNN (LPCC-S)
Entity Type:Individual
Prefix:
First Name:TRACIE
Middle Name:LYNN
Last Name:KELLER
Suffix:
Gender:F
Credentials:LPCC-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1080 FISHINGER RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43221-2302
Mailing Address - Country:US
Mailing Address - Phone:614-822-7819
Mailing Address - Fax:614-372-5590
Practice Address - Street 1:1080 FISHINGER RD
Practice Address - Street 2:SUITE 103
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43221-2302
Practice Address - Country:US
Practice Address - Phone:614-822-7819
Practice Address - Fax:614-372-5590
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-09
Last Update Date:2015-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE.0900503101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health