Provider Demographics
NPI:1669656153
Name:KELLER, LAURI LYNN (LMSW)
Entity Type:Individual
Prefix:MS
First Name:LAURI
Middle Name:LYNN
Last Name:KELLER
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:976 DEVONSHIRE CT
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:48116-1707
Mailing Address - Country:US
Mailing Address - Phone:810-423-1008
Mailing Address - Fax:810-225-2474
Practice Address - Street 1:3820 PACKARD ST STE 160
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48108-5000
Practice Address - Country:US
Practice Address - Phone:810-423-1008
Practice Address - Fax:734-997-5055
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-20
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010888211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1942507579Medicaid