Provider Demographics
NPI:1780190769
Name:KELLER, KRISTEN M
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:M
Last Name:KELLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 W BRIDGE ST STE B
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43017-1141
Mailing Address - Country:US
Mailing Address - Phone:614-547-9233
Mailing Address - Fax:
Practice Address - Street 1:200 W BRIDGE ST STE B
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:OH
Practice Address - Zip Code:43017-1141
Practice Address - Country:US
Practice Address - Phone:614-547-9233
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-28
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.2103311101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2846675Medicaid