Provider Demographics
NPI:1114509775
Name:KELLER, STACEY (CPS)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:KELLER
Suffix:
Gender:F
Credentials:CPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1041 W BRIDGE ST # B5
Mailing Address - Street 2:
Mailing Address - City:PHOENIXVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19460-4342
Mailing Address - Country:US
Mailing Address - Phone:610-415-9301
Mailing Address - Fax:610-415-1656
Practice Address - Street 1:1041 W BRIDGE ST # B5
Practice Address - Street 2:
Practice Address - City:PHOENIXVILLE
Practice Address - State:PA
Practice Address - Zip Code:19460-4342
Practice Address - Country:US
Practice Address - Phone:610-415-9301
Practice Address - Fax:610-415-1656
Is Sole Proprietor?:No
Enumeration Date:2021-04-23
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist