Healthcare Provider Details

I. General information

NPI: 1124143268
Provider Name (Legal Business Name): MRS. KIM LOUISE KELLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1004 LITTLESTOWN PIKE STE A3
WESTMINSTER MD
21157-3007
US

IV. Provider business mailing address

1901 BOWERSOX RD
NEW WINDSOR MD
21776-8613
US

V. Phone/Fax

Practice location:
  • Phone: 410-751-6858
  • Fax: 410-751-8999
Mailing address:
  • Phone: 410-875-3364
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA3032
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: