Provider Demographics
NPI:1245203264
Name:KELLER, NIOMI M (MPT)
Entity Type:Individual
Prefix:
First Name:NIOMI
Middle Name:M
Last Name:KELLER
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 HERITAGE WAY
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-3100
Mailing Address - Country:US
Mailing Address - Phone:406-407-7990
Mailing Address - Fax:855-928-0774
Practice Address - Street 1:419 W 9TH ST
Practice Address - Street 2:
Practice Address - City:LIBBY
Practice Address - State:MT
Practice Address - Zip Code:59923-1766
Practice Address - Country:US
Practice Address - Phone:406-293-8942
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1302225100000X
SD1272225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND54915OtherND MEDICAID
SD1245203261OtherNPI
SD4995084OtherWELLMARK BCBS
SD5834650Medicaid
SD5834650Medicaid