Provider Demographics
NPI:1437174067
Name:KELLER, REBECCA WOLFE (LCSW)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:WOLFE
Last Name:KELLER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:576 JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:FORT EUSTIS
Mailing Address - State:VA
Mailing Address - Zip Code:23604-1373
Mailing Address - Country:US
Mailing Address - Phone:757-314-7500
Mailing Address - Fax:757-314-7854
Practice Address - Street 1:576 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:FORT EUSTIS
Practice Address - State:VA
Practice Address - Zip Code:23604-1373
Practice Address - Country:US
Practice Address - Phone:757-314-7500
Practice Address - Fax:757-314-7854
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2013-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040030371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA192000OtherBC
VA010259282Medicaid
VA009195C90Medicare ID - Type UnspecifiedMEDICARE