Provider Demographics
NPI:1699238022
Name:KELLER, MEGAN LOIS (OTR/L)
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:LOIS
Last Name:KELLER
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31201 CHICAGO RD S
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-5527
Mailing Address - Country:US
Mailing Address - Phone:586-558-9705
Mailing Address - Fax:
Practice Address - Street 1:22731 NEWMAN ST STE 100B
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-2023
Practice Address - Country:US
Practice Address - Phone:313-791-0616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-11
Last Update Date:2025-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201013977225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI381958736Medicaid
30697OtherBCBSM