Provider Demographics
NPI:1326056441
Name:KELLER, VIRGINIA M (MC, LPC)
Entity Type:Individual
Prefix:MRS
First Name:VIRGINIA
Middle Name:M
Last Name:KELLER
Suffix:
Gender:F
Credentials:MC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11020 N TATUM BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028-6072
Mailing Address - Country:US
Mailing Address - Phone:602-996-8619
Mailing Address - Fax:602-996-7932
Practice Address - Street 1:11020 N TATUM BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85028-6072
Practice Address - Country:US
Practice Address - Phone:602-996-8619
Practice Address - Fax:602-996-7932
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-0139101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor