Provider Demographics
NPI:1659319440
Name:KELLER, CHRISTOPHER BLAINE (MSPT)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:BLAINE
Last Name:KELLER
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 PEACHTREE CT
Mailing Address - Street 2:SUITE 105
Mailing Address - City:HOLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11741-4616
Mailing Address - Country:US
Mailing Address - Phone:631-467-3700
Mailing Address - Fax:631-467-0928
Practice Address - Street 1:71 LONGVIEW DR
Practice Address - Street 2:
Practice Address - City:QUEENSBURY
Practice Address - State:NY
Practice Address - Zip Code:12804-5936
Practice Address - Country:US
Practice Address - Phone:518-832-7875
Practice Address - Fax:518-832-7876
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-03
Last Update Date:2016-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO8813225100000X
NY034111225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO66371821Medicaid
CO66371821Medicaid