Provider Demographics
NPI:1780809822
Name:KELLER, TANYA A (MS CCC-SLP EDS)
Entity type:Individual
Prefix:
First Name:TANYA
Middle Name:A
Last Name:KELLER
Suffix:
Gender:F
Credentials:MS CCC-SLP EDS
Other - Prefix:
Other - First Name:TANYA
Other - Middle Name:
Other - Last Name:SCOTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4735 BANCROFT ST APT 6
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92116-1667
Mailing Address - Country:US
Mailing Address - Phone:617-780-5193
Mailing Address - Fax:619-362-9930
Practice Address - Street 1:4735 BANCROFT ST APT 6
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92116-1667
Practice Address - Country:US
Practice Address - Phone:617-780-5193
Practice Address - Fax:619-362-9930
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6650235Z00000X
CASP27018235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MASP0175OtherBLUE CROSS BLUE SHIELD