Basic Information
| Provider Information | |||||||||
| NPI: | 1629213202 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLER | ||||||||
| FirstName: | KATHERINE | ||||||||
| MiddleName: | MAURINE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | L.C.S.W. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 87329 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850807329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6234347604 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 500 HIGHWAY 89 NORTH | ||||||||
| Address2: | NORTHERN ARIZONA VA HEALTH CARE SYSTEM | ||||||||
| City: | PRESCOTT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 86313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9284454860 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/10/2008 | ||||||||
| LastUpdateDate: | 12/10/2008 | ||||||||
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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 | 1041C0700X | LCS 6116 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 00122-C | NV | N | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.