Basic Information
| Provider Information | |||||||||
| NPI: | 1063579183 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KEELER | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | H. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 259 ROCK ST APT A10 | ||||||||
| Address2: | |||||||||
| City: | NORWOOD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 020624977 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7817699689 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 687 HIGHLAND AVE | ||||||||
| Address2: | |||||||||
| City: | NEEDHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024942232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6172543800 | ||||||||
| FaxNumber: | 6177791482 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2007 | ||||||||
| LastUpdateDate: | 03/11/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 7092 | MA | N | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103G00000X | 7092 | MA | Y | Behavioral Health & Social Service Providers | Clinical Neuropsychologist |
ID Information
| ID | Type | State | Issuer | Description | W06000 | 01 | MA | BLUE CROSS-BLUE SHIELD | OTHER | 110022270A | 05 | MA | MEDICAID | 0500054 | 05 | MA | MEDICAID |