Provider Demographics
NPI:1700831427
Name:KELLER, MARTIN E (EDD ABPP)
Entity Type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:E
Last Name:KELLER
Suffix:
Gender:M
Credentials:EDD ABPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11020 N TATUM BLVD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028-6072
Mailing Address - Country:US
Mailing Address - Phone:602-996-8619
Mailing Address - Fax:602-996-7932
Practice Address - Street 1:11020 N TATUM BLVD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85028-6072
Practice Address - Country:US
Practice Address - Phone:602-996-8619
Practice Address - Fax:602-996-7932
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ503103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
80092Medicare ID - Type Unspecified
R32534Medicare UPIN