Basic Information
| Provider Information | |||||||||
| NPI: | 1659091502 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLER | ||||||||
| FirstName: | ERNEST | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | II | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5707 N 22ND ST | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336104350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8132398069 | ||||||||
| FaxNumber: | 8132317324 | ||||||||
| Practice Location | |||||||||
| Address1: | 5707 N 22ND ST | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336104350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8132398069 | ||||||||
| FaxNumber: | 8132317324 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2022 | ||||||||
| LastUpdateDate: | 08/31/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.