Provider Demographics
NPI:1568516185
Name:KELLER, MARILYN J (SLP)
Entity Type:Individual
Prefix:MRS
First Name:MARILYN
Middle Name:J
Last Name:KELLER
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 4TH ST NW
Mailing Address - Street 2:
Mailing Address - City:MANDAN
Mailing Address - State:ND
Mailing Address - Zip Code:58554-2542
Mailing Address - Country:US
Mailing Address - Phone:701-663-8113
Mailing Address - Fax:
Practice Address - Street 1:406 4TH ST NW
Practice Address - Street 2:
Practice Address - City:MANDAN
Practice Address - State:ND
Practice Address - Zip Code:58554-2912
Practice Address - Country:US
Practice Address - Phone:701-663-7491
Practice Address - Fax:701-667-0984
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND121235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND58552Medicaid