=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871175836
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WARREN D KELLER PHD LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/28/2021
-----------------------------------------------------
Last Update Date | 04/28/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 501 GOODLETTE RD STE B206
-----------------------------------------------------
City | NAPLES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34102-5473
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-695-2032
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 501 GOODLETTE RD STE B206
-----------------------------------------------------
City | NAPLES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34102-5473
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-695-2032
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BUSINESS MANAGER
-----------------------------------------------------
Name | DEBORAH NEWBERRY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 716-695-2032
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------