Basic Information
| Provider Information | |||||||||
| NPI: | 1669883336 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KELLER | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | PSY.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 409099 | ||||||||
| Address2: | |||||||||
| City: | IONE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956409099 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2092744911 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4001 HIGHWAY 104 | ||||||||
| Address2: | |||||||||
| City: | IONE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956409099 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2092744911 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2014 | ||||||||
| LastUpdateDate: | 05/15/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | PSY19670 | CA | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.