Provider Demographics
NPI:1114706421
Name:KELLER, WADE (MA, LAMFT)
Entity Type:Individual
Prefix:
First Name:WADE
Middle Name:
Last Name:KELLER
Suffix:
Gender:M
Credentials:MA, LAMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15852 PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:PRIOR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55372-2270
Mailing Address - Country:US
Mailing Address - Phone:612-991-2937
Mailing Address - Fax:
Practice Address - Street 1:15852 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:PRIOR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55372-2270
Practice Address - Country:US
Practice Address - Phone:612-991-2937
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-26
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
MN4431106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health