Provider Demographics
NPI:1033679733
Name:KELLER, MATTHEA
Entity Type:Individual
Prefix:
First Name:MATTHEA
Middle Name:
Last Name:KELLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:728 E BISMARK AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99208-3503
Mailing Address - Country:US
Mailing Address - Phone:509-998-8242
Mailing Address - Fax:
Practice Address - Street 1:528 E SPOKANE FALLS BLVD STE 14
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99202-5081
Practice Address - Country:US
Practice Address - Phone:509-328-1582
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-20
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician