Provider Demographics
NPI:1780839431
Name:KELLER, COREEN WISTISEN (MPT)
Entity Type:Individual
Prefix:MRS
First Name:COREEN
Middle Name:WISTISEN
Last Name:KELLER
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2168 HILLCREST DR
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-5364
Mailing Address - Country:US
Mailing Address - Phone:208-734-9353
Mailing Address - Fax:
Practice Address - Street 1:560 SHOUP AVE W
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-5029
Practice Address - Country:US
Practice Address - Phone:208-737-2126
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-21
Last Update Date:2008-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-1441225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist