Provider Demographics
NPI:1255405791
Name:KELLER, SALLY (PHD)
Entity type:Individual
Prefix:DR
First Name:SALLY
Middle Name:
Last Name:KELLER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 NORTH DR
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-1333
Mailing Address - Country:US
Mailing Address - Phone:516-244-4148
Mailing Address - Fax:925-889-2838
Practice Address - Street 1:5 BOND ST
Practice Address - Street 2:STE. 4
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-2420
Practice Address - Country:US
Practice Address - Phone:516-244-4148
Practice Address - Fax:925-889-2838
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015413-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP93288Medicare ID - Type Unspecified