Provider Demographics
NPI:1265266274
Name:KELLER, CLARISSA (MS)
Entity type:Individual
Prefix:
First Name:CLARISSA
Middle Name:
Last Name:KELLER
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4512 INTERNATIONAL CT # D69
Mailing Address - Street 2:
Mailing Address - City:BERRIEN SPRINGS
Mailing Address - State:MI
Mailing Address - Zip Code:49103-1751
Mailing Address - Country:US
Mailing Address - Phone:269-362-4635
Mailing Address - Fax:
Practice Address - Street 1:1050 WILLSHIRE DR STE 175
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48277-0001
Practice Address - Country:US
Practice Address - Phone:800-693-1916
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-30
Last Update Date:2024-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6352000864103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist