Healthcare Provider Details

I. General information

NPI: 1598268237
Provider Name (Legal Business Name): THOMAS KELLER LPCC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2018
Last Update Date: 03/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 1ST AVE NE STE 310
MINNEAPOLIS MN
55413-2419
US

IV. Provider business mailing address

615 1ST AVE NE STE 310
MINNEAPOLIS MN
55413-2419
US

V. Phone/Fax

Practice location:
  • Phone: 612-436-0295
  • Fax: 612-436-0163
Mailing address:
  • Phone: 612-436-0295
  • Fax: 612-436-0163

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberCC01644
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: