Provider Demographics
NPI:1124534201
Name:LARUE, KELLY (RBT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:LARUE
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4224 HOLLAND RD STE 106
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452-1900
Mailing Address - Country:US
Mailing Address - Phone:757-416-5290
Mailing Address - Fax:
Practice Address - Street 1:4224 HOLLAND RD STE 106
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-1900
Practice Address - Country:US
Practice Address - Phone:757-416-5290
Practice Address - Fax:757-416-5290
Is Sole Proprietor?:No
Enumeration Date:2017-12-27
Last Update Date:2017-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VARBT-15-3084-15897106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician