Provider Demographics
NPI:1487003331
Name:KELLER, HOLLY ROSE
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:ROSE
Last Name:KELLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9960 N NEWPORT HWY # 1013
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99218-1366
Mailing Address - Country:US
Mailing Address - Phone:509-230-5022
Mailing Address - Fax:
Practice Address - Street 1:400 S JEFFERSON ST STE 109
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204-3144
Practice Address - Country:US
Practice Address - Phone:509-230-5022
Practice Address - Fax:509-230-5022
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-10
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60639413101Y00000X
WAMC60682882101YM0800X
LH61337830101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor