Provider Demographics
NPI:1760021919
Name:KELLER, DAVID (COTA)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:
Last Name:KELLER
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2345 S HOWELL AVE APT 311
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53207-1646
Mailing Address - Country:US
Mailing Address - Phone:262-844-6840
Mailing Address - Fax:
Practice Address - Street 1:19525 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045-4107
Practice Address - Country:US
Practice Address - Phone:262-785-1114
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-04
Last Update Date:2020-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5324-27224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant