Provider Demographics
NPI:1497187264
Name:KELLER, KATHERINE ELIZABETH
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:ELIZABETH
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 1:2 BLACK GUM TREE LN
Mailing Address - Street 2:
Mailing Address - City:KINGS PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11754-1747
Mailing Address - Country:US
Mailing Address - Phone:631-404-9077
Mailing Address - Fax:
Practice Address - Street 1:2 BLACK GUM TREE LN
Practice Address - Street 2:
Practice Address - City:KINGS PARK
Practice Address - State:NY
Practice Address - Zip Code:11754-1747
Practice Address - Country:US
Practice Address - Phone:631-404-9077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-05
Last Update Date:2013-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst