Provider Demographics
NPI:1619499472
Name:KELLER, SHELLEY A (BSW, LSW)
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:A
Last Name:KELLER
Suffix:
Gender:F
Credentials:BSW, LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1040 S WINTER ST STE 1022
Mailing Address - Street 2:
Mailing Address - City:ADRIAN
Mailing Address - State:MI
Mailing Address - Zip Code:49221-3876
Mailing Address - Country:US
Mailing Address - Phone:517-263-8905
Mailing Address - Fax:
Practice Address - Street 1:1040 S WINTER ST STE 1022
Practice Address - Street 2:
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-3876
Practice Address - Country:US
Practice Address - Phone:517-263-8905
Practice Address - Fax:517-265-8237
Is Sole Proprietor?:No
Enumeration Date:2017-07-13
Last Update Date:2019-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011037811041C0700X
OHS.14506701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical