Healthcare Provider Details

I. General information

NPI: 1386558120
Provider Name (Legal Business Name): STEPHEN KELLER
Entity Type: Individual
Gender: Male
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

2625 BUTTERFIELD RD STE 301
OAK BROOK IL
60523-1234
US

IV. Provider business mailing address

2625 BUTTERFIELD RD STE 301
OAK BROOK IL
60523-1234
US

V. Phone/Fax

Practice location:
  • Phone: 630-522-3124
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071.011253
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: