Provider Demographics
NPI:1912383506
Name:KEELER, PATRICIA A
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:A
Last Name:KEELER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:880 SE 82ND DRIVE
Mailing Address - Street 2:
Mailing Address - City:GLADSTONE
Mailing Address - State:OR
Mailing Address - Zip Code:97027
Mailing Address - Country:US
Mailing Address - Phone:503-659-5515
Mailing Address - Fax:
Practice Address - Street 1:880 SE 82ND DRIVE
Practice Address - Street 2:
Practice Address - City:GLADSTONE
Practice Address - State:OR
Practice Address - Zip Code:97027
Practice Address - Country:US
Practice Address - Phone:503-659-5515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-05
Last Update Date:2015-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR164936Medicaid