Provider Demographics
NPI:1205569167
Name:KELLER, MARISSA DANIELLE (BCBA)
Entity type:Individual
Prefix:MRS
First Name:MARISSA
Middle Name:DANIELLE
Last Name:KELLER
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 BANKS AVE
Mailing Address - Street 2:
Mailing Address - City:MCADOO
Mailing Address - State:PA
Mailing Address - Zip Code:18237-2508
Mailing Address - Country:US
Mailing Address - Phone:888-726-4774
Mailing Address - Fax:
Practice Address - Street 1:45 ROUTE 11
Practice Address - Street 2:
Practice Address - City:SHAMOKIN DAM
Practice Address - State:PA
Practice Address - Zip Code:17876-9116
Practice Address - Country:US
Practice Address - Phone:570-931-3849
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-07
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABH003476103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst