Provider Demographics
NPI:1407879281
Name:KELLER, RANDALL LAUREN (PHD)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:LAUREN
Last Name:KELLER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8510 34TH AVE
Mailing Address - Street 2:APT. 320
Mailing Address - City:JACKSON HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11372-3244
Mailing Address - Country:US
Mailing Address - Phone:347-645-2919
Mailing Address - Fax:718-334-5082
Practice Address - Street 1:11021 73RD RD APT 1J
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-6369
Practice Address - Country:US
Practice Address - Phone:347-645-2919
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013488103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02165057Medicaid
NY02165057Medicaid