Provider Demographics
NPI:1326551813
Name:KELLER, PHILIP RAYMOND
Entity Type:Individual
Prefix:MR
First Name:PHILIP
Middle Name:RAYMOND
Last Name:KELLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27777 INKSTER RD STE 100
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-5326
Mailing Address - Country:US
Mailing Address - Phone:248-299-0030
Mailing Address - Fax:
Practice Address - Street 1:44 SCHOOL ST RM 325
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02108
Practice Address - Country:US
Practice Address - Phone:248-299-0030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-07
Last Update Date:2019-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2404103K00000X, 103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty