Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YP2500X | Professional Counselor |
NPI | 1003065632 |
---|---|
Provider Name | Heather Keller |
First Address | Lakeside, AZ 85929-6807 |
Second Address | Lakeside, AZ 85929-6807 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 18/09/2008 |
Last Update Date | 15/02/2021 |