MEDICARE: DR. RANDALL LAUREN KELLER PH.D.

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	103T00000X	Psychologist	013488	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1407879281
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RANDALL LAUREN KELLER PH.D.

Provider Business Mailing Address
First Line	:	8510 34TH AVE
Second Line	:	APT. 320
City	:	JACKSON HEIGHTS
State	:	NY
Zip	:	11372-3244
Country	:	US
Telephone Number	:	347-645-2919
Fax Number	:	718-334-5082

Provider Business Practice Location Address
First Line	:	11021 73RD RD APT 1J
Second Line	:
City	:	FOREST HILLS
State	:	NY
Zip	:	11375-6369
Country	:	US
Telephone Number	:	347-645-2919
Fax Number	:

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

Provider Enumeration Date	:	07/25/2006
Last Update Date	:	04/22/2008

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