Provider Demographics
NPI:1245622752
Name:KELLER, MARY (LPC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:KELLER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:LIZ
Other - Middle Name:
Other - Last Name:KELLER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPC
Mailing Address - Street 1:1944 BRANNAN RD
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-4310
Mailing Address - Country:US
Mailing Address - Phone:678-289-6981
Mailing Address - Fax:
Practice Address - Street 1:1944 BRANNAN RD
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-4310
Practice Address - Country:US
Practice Address - Phone:678-289-6981
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-21
Last Update Date:2015-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC008089101Y00000X, 101YM0800X, 101YP1600X, 101YP2500X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist