Provider Demographics
NPI:1912914375
Name:KELLER, THOMAS ALLEN (PHD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:ALLEN
Last Name:KELLER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7863 LA MESA BLVD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91941-3657
Mailing Address - Country:US
Mailing Address - Phone:619-698-9525
Mailing Address - Fax:619-698-9546
Practice Address - Street 1:7863 LA MESA BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91941-3657
Practice Address - Country:US
Practice Address - Phone:619-698-9525
Practice Address - Fax:619-698-9546
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 12961103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY129610Medicaid
CAPSY129610Medicaid