Provider Demographics
NPI:1417735713
Name:KELLER, ALLISON GRACE (HIS)
Entity Type:Individual
Prefix:
First Name:ALLISON
Middle Name:GRACE
Last Name:KELLER
Suffix:
Gender:F
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:318 E SOUTH MAIN ST STE H
Mailing Address - Street 2:
Mailing Address - City:WAXHAW
Mailing Address - State:NC
Mailing Address - Zip Code:28173-9912
Mailing Address - Country:US
Mailing Address - Phone:704-256-1634
Mailing Address - Fax:
Practice Address - Street 1:318 E SOUTH MAIN ST STE H
Practice Address - Street 2:
Practice Address - City:WAXHAW
Practice Address - State:NC
Practice Address - Zip Code:28173-9912
Practice Address - Country:US
Practice Address - Phone:704-256-1634
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-18
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1666237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist