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General NPI Number Information
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NPI Number | 1407879281
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Entity Type | Individual
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Provider Name | RANDALL LAUREN KELLER PH.D.
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Gender | Male
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Dates
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Enumeration Date | 07/25/2006
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Last Update Date | 04/22/2008
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Provider Practice Location Address
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Address Line | 11021 73RD RD APT 1J
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City | FOREST HILLS
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State | NY
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Zip | 11375-6369
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Country | US
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Telephone | 347-645-2919
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Fax |
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Provider Business Mailing Address
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Address Line | 8510 34TH AVE APT. 320
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City | JACKSON HEIGHTS
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State | NY
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Zip | 11372-3244
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Country | US
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Telephone | 347-645-2919
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Fax | 718-334-5082
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 013488
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License Number State | NY
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