Provider Demographics
NPI:1437340528
Name:KELLER, JAMES RILEY (PHD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:RILEY
Last Name:KELLER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:JIM
Other - Middle Name:R
Other - Last Name:KELLER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:PO BOX 7083
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73083-7083
Mailing Address - Country:US
Mailing Address - Phone:405-359-2422
Mailing Address - Fax:
Practice Address - Street 1:1800 RENAISSANCE BLVD
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-3023
Practice Address - Country:US
Practice Address - Phone:405-359-2422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-05
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK854103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service