Provider Demographics
NPI:1003450255
Name:KELLER, AMY LYNN
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:LYNN
Last Name:KELLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:LYNN
Other - Last Name:GROGG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:476 PORTLAND WAY N
Mailing Address - Street 2:
Mailing Address - City:GALION
Mailing Address - State:OH
Mailing Address - Zip Code:44833-1115
Mailing Address - Country:US
Mailing Address - Phone:419-468-3676
Mailing Address - Fax:
Practice Address - Street 1:476 PORTLAND WAY N
Practice Address - Street 2:
Practice Address - City:GALION
Practice Address - State:OH
Practice Address - Zip Code:44833-1115
Practice Address - Country:US
Practice Address - Phone:419-468-3676
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-31
Last Update Date:2019-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP.06453235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1965Medicaid