MEDICARE: MS. CHARLIE KELLER LPC

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	101YM0800X	Mental Health Counselor	81810	TX

General Provider Information

NPI Number	:	1124898150
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. CHARLIE KELLER LPC

Provider Business Mailing Address
First Line	:	7201 BROADWAY STE 218
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78209-3773
Country	:	US
Telephone Number	:	210-960-6828
Fax Number	:

Provider Business Practice Location Address
First Line	:	7201 BROADWAY STE 218
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78209-3773
Country	:	US
Telephone Number	:	210-960-6828
Fax Number	:

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

Provider Enumeration Date	:	01/02/2024
Last Update Date	:	03/27/2026

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