Healthcare Provider Details

I. General information

NPI: 1730406661
Provider Name (Legal Business Name): NICOLE LEANNA KELLER MS, PCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2010
Last Update Date: 05/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 E MAIN ST
GREENVILLE OH
45331-1913
US

IV. Provider business mailing address

600 FESSLER BUXTON RD
RUSSIA OH
45363-9641
US

V. Phone/Fax

Practice location:
  • Phone: 937-548-1635
  • Fax: 937-548-1500
Mailing address:
  • Phone: 937-548-1635
  • Fax: 937-548-1500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: