Provider Demographics
NPI:1598329112
Name:KELLER, JOSEPH M
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:M
Last Name:KELLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 OLD CANTON RD
Mailing Address - Street 2:
Mailing Address - City:BALL GROUND
Mailing Address - State:GA
Mailing Address - Zip Code:30107-4002
Mailing Address - Country:US
Mailing Address - Phone:678-662-2284
Mailing Address - Fax:
Practice Address - Street 1:105 ARNOLD MILL RD
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-5027
Practice Address - Country:US
Practice Address - Phone:770-926-0016
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-29
Last Update Date:2019-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTA003393225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant