Provider Demographics
NPI:1710627922
Name:KELLER, DOMINIK LIA (PHD)
Entity Type:Individual
Prefix:DR
First Name:DOMINIK
Middle Name:LIA
Last Name:KELLER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5915 GETWELL RD BLDG B
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38672-6455
Mailing Address - Country:US
Mailing Address - Phone:662-349-2979
Mailing Address - Fax:
Practice Address - Street 1:5915 GETWELL RD BLDG B
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38672-6455
Practice Address - Country:US
Practice Address - Phone:662-349-2979
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-29
Last Update Date:2022-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS621149103TS0200X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS200000200Medicaid
MA110026265EMedicaid