Provider Demographics
NPI:1700262151
Name:KELLER, KOURTNEY
Entity Type:Individual
Prefix:
First Name:KOURTNEY
Middle Name:
Last Name:KELLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 TEAK CT
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34472-9042
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10252 SE US HIGHWAY 441 UNIT 3
Practice Address - Street 2:
Practice Address - City:BELLEVIEW
Practice Address - State:FL
Practice Address - Zip Code:34420-7822
Practice Address - Country:US
Practice Address - Phone:352-559-2539
Practice Address - Fax:352-547-5787
Is Sole Proprietor?:No
Enumeration Date:2015-08-08
Last Update Date:2018-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician