Provider Demographics
NPI:1639511447
Name:KELLER, TERESA LYNN (PTA)
Entity Type:Individual
Prefix:MRS
First Name:TERESA
Middle Name:LYNN
Last Name:KELLER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6088 LINCOLN BLVD
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-5050
Mailing Address - Country:US
Mailing Address - Phone:810-695-9751
Mailing Address - Fax:
Practice Address - Street 1:8481 HOLLY ROAD
Practice Address - Street 2:
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439
Practice Address - Country:US
Practice Address - Phone:810-694-1711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-22
Last Update Date:2013-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502001729225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5502001729OtherDEPARTMENT OF LICENSING AND REGULATORY AFFAIRS