Provider Demographics
NPI:1265668933
Name:KELLER, ANNE D (LCSW)
Entity Type:Individual
Prefix:
First Name:ANNE
Middle Name:D
Last Name:KELLER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6510 GRAND TETON PLAZA
Mailing Address - Street 2:STE 406
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53719-1029
Mailing Address - Country:US
Mailing Address - Phone:608-833-9290
Mailing Address - Fax:608-833-9691
Practice Address - Street 1:6510 GRAND TETON PLAZA
Practice Address - Street 2:STE 406
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53719-1029
Practice Address - Country:US
Practice Address - Phone:608-833-9290
Practice Address - Fax:608-833-9691
Is Sole Proprietor?:No
Enumeration Date:2009-06-08
Last Update Date:2010-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5961231041C0700X
WI596-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1265668933Medicaid
WI840270031Medicare PIN