MEDICARE: KENNETH J KELLER PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	3461	AZ

General Provider Information

NPI Number	:	1114075207
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNETH J KELLER PHD

Provider Business Mailing Address
First Line	:	5151 E BROADWAY BLVD
Second Line	:	# 720
City	:	TUCSON
State	:	AZ
Zip	:	85711-3705
Country	:	US
Telephone Number	:	520-790-7583
Fax Number	:	520-790-5175

Provider Business Practice Location Address
First Line	:	5151 E BROADWAY BLVD
Second Line	:	# 720
City	:	TUCSON
State	:	AZ
Zip	:	85711-3705
Country	:	US
Telephone Number	:	520-790-7583
Fax Number	:	520-790-5175

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/08/2007
Last Update Date	:	11/08/2007

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