Healthcare Provider Details

I. General information

NPI: 1437340528
Provider Name (Legal Business Name): JAMES RILEY KELLER PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: JIM R KELLER PHD

II. Dates (important events)

Enumeration Date: 08/05/2007
Last Update Date: 09/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 RENAISSANCE BLVD
EDMOND OK
73013-3023
US

IV. Provider business mailing address

PO BOX 7083
EDMOND OK
73083-7083
US

V. Phone/Fax

Practice location:
  • Phone: 405-359-2422
  • Fax:
Mailing address:
  • Phone: 405-359-2422
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number854
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: