1164753935 NPI number — MRS. KELLY LUTHER KOEBEL LPC

Table of content: MRS. KELLY LUTHER KOEBEL LPC (NPI 1164753935)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164753935 NPI number — MRS. KELLY LUTHER KOEBEL LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOEBEL
Provider First Name:
KELLY
Provider Middle Name:
LUTHER
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LUTHER
Provider Other First Name:
KELLY
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
LPC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1164753935
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/20/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
24 CLAY ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARTINSVILLE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24112-2810
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
276-632-7128
Provider Business Mailing Address Fax Number:
276-632-0127

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
24 CLAY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARTINSVILLE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24112-2810
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
276-632-7128
Provider Business Practice Location Address Fax Number:
276-632-0127
Provider Enumeration Date:
01/19/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  0701004759 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 004945221 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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