Healthcare Provider Details

I. General information

NPI: 1245203264
Provider Name (Legal Business Name): NIOMI M KELLER MPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2006
Last Update Date: 07/11/2023
Certification Date: 07/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

419 W 9TH ST
LIBBY MT
59923-1766
US

IV. Provider business mailing address

25 HERITAGE WAY
KALISPELL MT
59901-3100
US

V. Phone/Fax

Practice location:
  • Phone: 406-293-8942
  • Fax:
Mailing address:
  • Phone: 406-407-7990
  • Fax: 855-928-0774

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1302
License Number StateND
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1272
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: