MEDICARE: SHELLY D KELLER LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	2009014918	MO

General Provider Information

NPI Number	:	1063642700
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHELLY D KELLER LCSW

Provider Business Mailing Address
First Line	:	120 CHEROKEE LN
Second Line	:
City	:	LAKE WINNEBAGO
State	:	MO
Zip	:	64034-9304
Country	:	US
Telephone Number	:	816-623-9711
Fax Number	:

Provider Business Practice Location Address
First Line	:	120 CHEROKEE LN
Second Line	:
City	:	LAKE WINNEBAGO
State	:	MO
Zip	:	64034-9304
Country	:	US
Telephone Number	:	816-623-9711
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/15/2009
Last Update Date	:	07/15/2009

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