Provider Demographics
NPI:1811364987
Name:KELLER, NICHOLAS (LICSW)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:KELLER
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:522 MISSISSIPPI RIVER BLVD N
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-5295
Mailing Address - Country:US
Mailing Address - Phone:612-616-8265
Mailing Address - Fax:
Practice Address - Street 1:2324 UNIVERSITY AVE W
Practice Address - Street 2:SUITE 120
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55114-1843
Practice Address - Country:US
Practice Address - Phone:651-212-5386
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-25
Last Update Date:2015-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN194531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical