Provider Demographics
NPI:1891052908
Name:KELLER, WALT (HSPP)
Entity Type:Individual
Prefix:DR
First Name:WALT
Middle Name:
Last Name:KELLER
Suffix:
Gender:M
Credentials:HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 11
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47402-0011
Mailing Address - Country:US
Mailing Address - Phone:812-336-3570
Mailing Address - Fax:812-336-9010
Practice Address - Street 1:645 N WALNUT ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47404-3846
Practice Address - Country:US
Practice Address - Phone:812-336-3570
Practice Address - Fax:812-336-9010
Is Sole Proprietor?:No
Enumeration Date:2012-04-13
Last Update Date:2012-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20040042103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical