Healthcare Provider Details

I. General information

NPI: 1477574788
Provider Name (Legal Business Name): PEYTON RANDOLPH KELLER LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 01/11/2026
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5TH AVENUE AND ROOSEVELT RD.
HINES IL
60641
US

IV. Provider business mailing address

1310 N RITCHIE CT APT. 15C
CHICAGO IL
60610-2168
US

V. Phone/Fax

Practice location:
  • Phone: 708-202-4952
  • Fax: 708-202-4954
Mailing address:
  • Phone: 708-202-4952
  • Fax: 708-202-4954

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: