Provider Demographics
NPI:1093150112
Name:KELLER, JAMES MARK (M ED)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:MARK
Last Name:KELLER
Suffix:
Gender:M
Credentials:M ED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1543 LAKE BALDWIN LN
Mailing Address - Street 2:SUITE B
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32814-6695
Mailing Address - Country:US
Mailing Address - Phone:407-894-5202
Mailing Address - Fax:
Practice Address - Street 1:1543 LAKE BALDWIN LN
Practice Address - Street 2:SUITE B
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32814-6695
Practice Address - Country:US
Practice Address - Phone:407-894-5202
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-02
Last Update Date:2013-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH8431101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health