Basic Information
| Provider Information | |||||||||
| NPI: | 1083053862 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLER | ||||||||
| FirstName: | SUZANNE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KELLER | ||||||||
| OtherFirstName: | ANNA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3800 COUNTRY CLUB DR | ||||||||
| Address2: | APT 2 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900193301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3237341076 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 425 S BROADWAY | ||||||||
| Address2: | SHARE | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2132130100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2013 | ||||||||
| LastUpdateDate: | 07/11/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.