=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053346171
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TRISTAN GLENN KELLER LISW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/11/2006
-----------------------------------------------------
Last Update Date | 07/09/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2025 E AZTEC AVE
-----------------------------------------------------
City | GALLUP
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87301-4803
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-863-3828
-----------------------------------------------------
Fax | 505-863-6612
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 219 BOULDER RD
-----------------------------------------------------
City | GALLUP
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87301-5795
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-863-3604
-----------------------------------------------------
Fax | 505-863-6612
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | I-05565
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------