Provider Demographics
NPI:1750541835
Name:KELLER, KATHRYN M (PHD)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:M
Last Name:KELLER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:M
Other - Last Name:BJERKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:903 MINERAL POINT AVE
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53548-2970
Mailing Address - Country:US
Mailing Address - Phone:608-756-5555
Mailing Address - Fax:608-756-0174
Practice Address - Street 1:903 MINERAL POINT AVE
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53548-2970
Practice Address - Country:US
Practice Address - Phone:608-756-5555
Practice Address - Fax:608-756-0174
Is Sole Proprietor?:No
Enumeration Date:2008-06-12
Last Update Date:2017-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3906125101YP2500X
WI2891-57103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIKELLEKA2OtherMERCYCARE INSURANCE
WI1750541835OtherBCBSWI
WI1750541835Medicaid
WI1750541835OtherDEAN HEALTH PLAN
WI84908-0045Medicare PIN