Provider Demographics
NPI:1902203631
Name:TIFFANY L KELLER PSYD
Entity Type:Organization
Organization Name:TIFFANY L KELLER PSYD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:L
Authorized Official - Last Name:KELLER
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:773-931-6430
Mailing Address - Street 1:2310 N. MONTICELLO AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647
Mailing Address - Country:US
Mailing Address - Phone:773-931-6430
Mailing Address - Fax:
Practice Address - Street 1:30 N. MICHIGAN
Practice Address - Street 2:1124
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602
Practice Address - Country:US
Practice Address - Phone:773-931-6430
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-24
Last Update Date:2014-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071007170103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Single Specialty