Provider Demographics
NPI:1437475258
Name:KELLER, MARY JANE (LPC)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:JANE
Last Name:KELLER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 CARLISLE
Mailing Address - Street 2:SUITE 109
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75204
Mailing Address - Country:US
Mailing Address - Phone:469-371-3407
Mailing Address - Fax:214-245-5880
Practice Address - Street 1:3100 CARLISLE
Practice Address - Street 2:SUITE 109
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75204
Practice Address - Country:US
Practice Address - Phone:469-371-3407
Practice Address - Fax:214-245-5880
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-19
Last Update Date:2010-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX62580101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional