Provider Demographics
NPI:1770960650
Name:TRACIE L KELLER, LPCC, LLC
Entity type:Organization
Organization Name:TRACIE L KELLER, LPCC, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TRACIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:KELLER
Authorized Official - Suffix:
Authorized Official - Credentials:LPCC-S
Authorized Official - Phone:614-822-7819
Mailing Address - Street 1:1080 FISHINGER RD STE 103
Mailing Address - Street 2:
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 STE 103
Practice Address - Street 2:
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-30
Last Update Date:2015-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE.0900503-SUPV101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty