Healthcare Provider Details

I. General information

NPI: 1194163774
Provider Name (Legal Business Name): KELLER LEE RICH LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2013
Last Update Date: 08/28/2024
Certification Date: 08/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5060 SHOREHAM PL STE 100
SAN DIEGO CA
92122-5904
US

IV. Provider business mailing address

5060 SHOREHAM PL STE 100
SAN DIEGO CA
92122-5904
US

V. Phone/Fax

Practice location:
  • Phone: 858-221-0344
  • Fax: 949-703-7489
Mailing address:
  • Phone: 858-221-0344
  • Fax: 949-703-7489

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number95120
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: