Provider Demographics
NPI:1841058807
Name:KELLER, KIMBERLY MELISSA (PSYD)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:MELISSA
Last Name:KELLER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:712 E WELLS ST APT 1
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-3914
Mailing Address - Country:US
Mailing Address - Phone:678-732-7074
Mailing Address - Fax:
Practice Address - Street 1:933 N MAYFAIR RD STE 101
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-3432
Practice Address - Country:US
Practice Address - Phone:678-732-7074
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-13
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3884-57103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical