Provider Demographics
NPI:1346676897
Name:KELLER, LISA J (PSYD, LP)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:J
Last Name:KELLER
Suffix:
Gender:F
Credentials:PSYD, LP
Other - Prefix:DR
Other - First Name:LISA
Other - Middle Name:J
Other - Last Name:KELLER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PSYD
Mailing Address - Street 1:3505 8TH ST S STE 3
Mailing Address - Street 2:
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56560-5108
Mailing Address - Country:US
Mailing Address - Phone:701-532-0991
Mailing Address - Fax:701-532-0428
Practice Address - Street 1:3505 8TH ST S STE 3
Practice Address - Street 2:
Practice Address - City:MOORHEAD
Practice Address - State:MN
Practice Address - Zip Code:56560-5108
Practice Address - Country:US
Practice Address - Phone:701-532-0991
Practice Address - Fax:701-532-0428
Is Sole Proprietor?:No
Enumeration Date:2013-09-16
Last Update Date:2024-02-09
Deactivation Date:2023-09-07
Deactivation Code:
Reactivation Date:2023-09-21
Provider Licenses
StateLicense IDTaxonomies
MNLP6349103T00000X, 103T00000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNH400917182OtherENROLLMENT PART B