Provider Demographics
NPI:1043248800
Name:KELLER, JOHN W (PHD)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:W
Last Name:KELLER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:215 MOUNTAIN DR
Mailing Address - Street 2:STE. 106
Mailing Address - City:DESTIN
Mailing Address - State:FL
Mailing Address - Zip Code:32541-2346
Mailing Address - Country:US
Mailing Address - Phone:850-837-9100
Mailing Address - Fax:850-837-3774
Practice Address - Street 1:215 MOUNTAIN DR
Practice Address - Street 2:STE. 106
Practice Address - City:DESTIN
Practice Address - State:FL
Practice Address - Zip Code:32541-2346
Practice Address - Country:US
Practice Address - Phone:850-837-9100
Practice Address - Fax:850-837-3774
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2011-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY2338101YA0400X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL74093ZMedicare PIN