Provider Demographics
NPI:1871921700
Name:KELLER, CAROL (LCPC, NCC)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:KELLER
Suffix:
Gender:F
Credentials:LCPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12105 DARNESTOWN RD
Mailing Address - Street 2:SUITE 28
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20878-2217
Mailing Address - Country:US
Mailing Address - Phone:301-569-0134
Mailing Address - Fax:
Practice Address - Street 1:12105 DARNESTOWN RD
Practice Address - Street 2:SUITE 28
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20878-2217
Practice Address - Country:US
Practice Address - Phone:301-569-0134
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-01
Last Update Date:2016-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC6477101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD099789700Medicaid