Provider Demographics
NPI:1306819966
Name:KELLER, BRENDA LEA (PT)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:LEA
Last Name:KELLER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6438 S 164TH AVE
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68135-6340
Mailing Address - Country:US
Mailing Address - Phone:402-496-4666
Mailing Address - Fax:
Practice Address - Street 1:13110 BIRCH DR
Practice Address - Street 2:STE 164
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68164-4160
Practice Address - Country:US
Practice Address - Phone:402-496-4666
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2209225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist