Provider Demographics
NPI:1063642700
Name:KELLER, SHELLY D (LCSW)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:D
Last Name:KELLER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:SHELLY
Other - Middle Name:D
Other - Last Name:RIFFLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:120 CHEROKEE LN
Mailing Address - Street 2:
Mailing Address - City:LAKE WINNEBAGO
Mailing Address - State:MO
Mailing Address - Zip Code:64034-9304
Mailing Address - Country:US
Mailing Address - Phone:816-623-9711
Mailing Address - Fax:
Practice Address - Street 1:120 CHEROKEE LN
Practice Address - Street 2:
Practice Address - City:LAKE WINNEBAGO
Practice Address - State:MO
Practice Address - Zip Code:64034-9304
Practice Address - Country:US
Practice Address - Phone:816-623-9711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-15
Last Update Date:2009-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20090149181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical