Provider Demographics
NPI:1942603832
Name:KELLER, SUSANA
Entity Type:Individual
Prefix:
First Name:SUSANA
Middle Name:
Last Name:KELLER
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 1:8203 ARDMORE AVE
Mailing Address - Street 2:
Mailing Address - City:WYNDMOOR
Mailing Address - State:PA
Mailing Address - Zip Code:19038-8401
Mailing Address - Country:US
Mailing Address - Phone:215-514-4121
Mailing Address - Fax:
Practice Address - Street 1:8203 ARDMORE AVE
Practice Address - Street 2:
Practice Address - City:WYNDMOOR
Practice Address - State:PA
Practice Address - Zip Code:19038-8401
Practice Address - Country:US
Practice Address - Phone:215-514-4121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-06
Last Update Date:2014-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE1-0001368235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist