Provider Demographics
NPI:1164753935
Name:KOEBEL, KELLY LUTHER (LPC)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:LUTHER
Last Name:KOEBEL
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:MS
Other - First Name:KELLY
Other - Middle Name:MARIE
Other - Last Name:LUTHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:24 CLAY ST
Mailing Address - Street 2:
Mailing Address - City:MARTINSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24112-2810
Mailing Address - Country:US
Mailing Address - Phone:276-632-7128
Mailing Address - Fax:276-632-0127
Practice Address - Street 1:24 CLAY ST
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24112-2810
Practice Address - Country:US
Practice Address - Phone:276-632-7128
Practice Address - Fax:276-632-0127
Is Sole Proprietor?:No
Enumeration Date:2010-01-19
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701004759101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA004945221Medicaid