Provider Demographics
NPI:1083015879
Name:KELLER, ELLEN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:
Last Name:KELLER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:81 LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:DEER PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11729-7015
Mailing Address - Country:US
Mailing Address - Phone:631-902-0505
Mailing Address - Fax:
Practice Address - Street 1:81 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:DEER PARK
Practice Address - State:NY
Practice Address - Zip Code:11729-7015
Practice Address - Country:US
Practice Address - Phone:631-902-0505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-11
Last Update Date:2014-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013125103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical