Provider Demographics
NPI:1417921693
Name:KELLER, CHARLES W (PHD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:W
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 1:5502 58TH ST
Mailing Address - Street 2:SUITE 600
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79414-2000
Mailing Address - Country:US
Mailing Address - Phone:806-792-4713
Mailing Address - Fax:806-792-1506
Practice Address - Street 1:5502 58TH ST
Practice Address - Street 2:SUITE 600
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79414-2000
Practice Address - Country:US
Practice Address - Phone:806-792-4713
Practice Address - Fax:806-792-1506
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-15
Last Update Date:2017-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2-0861103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX035131401Medicaid
TX035131401Medicaid