Provider Demographics
NPI:1477727840
Name:KELLER, GAEDIN A (MA)
Entity type:Individual
Prefix:
First Name:GAEDIN
Middle Name:A
Last Name:KELLER
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3320 PENINSULA RD APT 149
Mailing Address - Street 2:
Mailing Address - City:OXNARD
Mailing Address - State:CA
Mailing Address - Zip Code:93035-4262
Mailing Address - Country:US
Mailing Address - Phone:619-507-3918
Mailing Address - Fax:
Practice Address - Street 1:3320 PENINSULA RD APT 149
Practice Address - Street 2:
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93035-4262
Practice Address - Country:US
Practice Address - Phone:619-507-3918
Practice Address - Fax:503-393-3135
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-16
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORT2083101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health