Provider Demographics
NPI:1871688721
Name:KELLER, SUSAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:
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 1:631 TENNESSEE ST
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94590-4432
Mailing Address - Country:US
Mailing Address - Phone:707-643-0258
Mailing Address - Fax:707-643-0115
Practice Address - Street 1:631 TENNESSEE ST
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94590-4432
Practice Address - Country:US
Practice Address - Phone:707-643-0258
Practice Address - Fax:707-643-0115
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY16445103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling