Provider Demographics
NPI:1952600983
Name:KELLER, CHAD JOHN (PHD)
Entity Type:Individual
Prefix:DR
First Name:CHAD
Middle Name:JOHN
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 1:7 ALBY ST APT 6
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-6281
Mailing Address - Country:US
Mailing Address - Phone:314-560-9055
Mailing Address - Fax:
Practice Address - Street 1:7700 CLAYTON RD STE 103
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63117-1345
Practice Address - Country:US
Practice Address - Phone:314-560-9055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-16
Last Update Date:2011-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010040873103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling