Provider Demographics
NPI:1669883336
Name:KELLER, KATHLEEN ANN (PSYD)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:ANN
Last Name:KELLER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 409099
Mailing Address - Street 2:
Mailing Address - City:IONE
Mailing Address - State:CA
Mailing Address - Zip Code:95640-9099
Mailing Address - Country:US
Mailing Address - Phone:209-274-4911
Mailing Address - Fax:
Practice Address - Street 1:4001 HIGHWAY 104
Practice Address - Street 2:
Practice Address - City:IONE
Practice Address - State:CA
Practice Address - Zip Code:95640-9099
Practice Address - Country:US
Practice Address - Phone:209-274-4911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-15
Last Update Date:2014-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY19670103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical