Provider Demographics
NPI:1952521650
Name:KELLER, SHANNON A
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:A
Last Name:KELLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1391 DELTA CORS
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30045-5407
Mailing Address - Country:US
Mailing Address - Phone:770-982-3138
Mailing Address - Fax:
Practice Address - Street 1:4823 N ROYAL ATLANTA DR
Practice Address - Street 2:SUITE C
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-3806
Practice Address - Country:US
Practice Address - Phone:770-939-2121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional