=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972480135
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TESS KELLER FAMILY THERAPIST PROFESSIONAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/19/2025
-----------------------------------------------------
Last Update Date | 08/19/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 920 SAMOA BLVD STE 203
-----------------------------------------------------
City | ARCATA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95521-6696
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-834-1311
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 776 BEVERLY WAY
-----------------------------------------------------
City | ARCATA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95521-6560
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-834-1311
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | TESS KELLER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 707-834-1311
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------