Provider Demographics
NPI:1700267226
Name:KELLER, STEPHANIE (PH D)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:KELLER
Suffix:
Gender:F
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 BEE ST
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29401-5703
Mailing Address - Country:US
Mailing Address - Phone:843-789-5011
Mailing Address - Fax:
Practice Address - Street 1:109 BEE ST
Practice Address - Street 2:MENTAL HEALTH SERVICE
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29401-5703
Practice Address - Country:US
Practice Address - Phone:843-789-5011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-10
Last Update Date:2015-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCXXXX103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical