Provider Demographics
NPI:1811257884
Name:KELLER, M MAXWELL (MFT)
Entity type:Individual
Prefix:
First Name:M
Middle Name:MAXWELL
Last Name:KELLER
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:132 GOUGH ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94102-5965
Mailing Address - Country:US
Mailing Address - Phone:415-894-5759
Mailing Address - Fax:
Practice Address - Street 1:110 GOUGH ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94102-5945
Practice Address - Country:US
Practice Address - Phone:415-894-5759
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-23
Last Update Date:2012-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC47750106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist