Provider Demographics
NPI:1912644436
Name:KELLER, JUSTIN LLOYD (DPT)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:LLOYD
Last Name:KELLER
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2505 8TH ST S
Mailing Address - Street 2:
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56560-4202
Mailing Address - Country:US
Mailing Address - Phone:219-233-3690
Mailing Address - Fax:
Practice Address - Street 1:641 41ST AVE S
Practice Address - Street 2:
Practice Address - City:MOORHEAD
Practice Address - State:MN
Practice Address - Zip Code:56560-6715
Practice Address - Country:US
Practice Address - Phone:701-205-7848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-16
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6394225100000X
MN4972225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist