Provider Demographics
NPI:1033367925
Name:KELLER, MICHELE COLLEEN (LAC, MA)
Entity Type:Individual
Prefix:MRS
First Name:MICHELE
Middle Name:COLLEEN
Last Name:KELLER
Suffix:
Gender:F
Credentials:LAC, MA
Other - Prefix:MISS
Other - First Name:MICHELE
Other - Middle Name:COLLEEN
Other - Last Name:COPP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAC, MA
Mailing Address - Street 1:T-9 FORT MISSOULA
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59804-7202
Mailing Address - Country:US
Mailing Address - Phone:406-532-8400
Mailing Address - Fax:406-543-9316
Practice Address - Street 1:1325 WYOMING ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-1725
Practice Address - Country:US
Practice Address - Phone:406-532-9800
Practice Address - Fax:406-541-3032
Is Sole Proprietor?:No
Enumeration Date:2008-09-04
Last Update Date:2008-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1251101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)