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General NPI Number Information
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NPI Number | 1902203631
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Entity Type | Organization
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Legal Business Name | TIFFANY L KELLER PSYD
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Dates
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Enumeration Date | 11/24/2014
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Last Update Date | 11/24/2014
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Provider Practice Location Address
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Address Line | 30 N. MICHIGAN 1124
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City | CHICAGO
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State | IL
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Zip | 60602
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Country | US
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Telephone | 773-931-6430
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Fax |
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Provider Business Mailing Address
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Address Line | 2310 N. MONTICELLO AVE
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City | CHICAGO
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State | IL
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Zip | 60647
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Country | US
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Telephone | 773-931-6430
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Fax |
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Authorized Official
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Title or Position | PSYCHOLOGIST
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Name | DR. TIFFANY L KELLER
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Credential | PSY.D.
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Telephone | 773-931-6430
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC2200X
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Taxonomy Name | Clinical Child & Adolescent Psychologist
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License Number | 071007170
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License Number State | IL
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