Healthcare Provider Details

I. General information

NPI: 1821902693
Provider Name (Legal Business Name): ALICE KELLER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2026
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 S INDIAN RIVER DR STE 202
FORT PIERCE FL
34950-4353
US

IV. Provider business mailing address

130 S INDIAN RIVER DR STE 202
FORT PIERCE FL
34950-4353
US

V. Phone/Fax

Practice location:
  • Phone: 772-279-4523
  • Fax: 772-272-8600
Mailing address:
  • Phone: 772-279-4523
  • Fax: 772-272-8600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: