Provider Demographics
NPI:1790232114
Name:KELLER, MADELEINE L (LPCC)
Entity type:Individual
Prefix:
First Name:MADELEINE
Middle Name:L
Last Name:KELLER
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2468 E 126TH ST UPPR
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44120-1046
Mailing Address - Country:US
Mailing Address - Phone:440-313-1923
Mailing Address - Fax:
Practice Address - Street 1:3569 RIDGE RD
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44102-5443
Practice Address - Country:US
Practice Address - Phone:216-281-0872
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-01
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.1700521101YM0800X
OHE1901494101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health