Provider Demographics
NPI:1326129867
Name:KELLER, MARY JANE (OTR CHT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JANE
Last Name:KELLER
Suffix:
Gender:F
Credentials:OTR CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 11
Mailing Address - Street 2:EXCEL REHAB AND SPINE CENTER INC
Mailing Address - City:MINOCQUA
Mailing Address - State:WI
Mailing Address - Zip Code:54548
Mailing Address - Country:US
Mailing Address - Phone:715-358-1929
Mailing Address - Fax:715-356-4031
Practice Address - Street 1:8554 HWY 51 N
Practice Address - Street 2:UNIT 617
Practice Address - City:MINOCQUA
Practice Address - State:WI
Practice Address - Zip Code:54548
Practice Address - Country:US
Practice Address - Phone:715-358-1929
Practice Address - Fax:715-356-4031
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1752026225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40811700Medicaid