MEDICARE: LISA KELLER MSC, LPC, CSAT

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	LPC-14464	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	LPC-14464	OTHER	AZ	LICENSED PROFESSIONAL COUNSELOR

General Provider Information

NPI Number	:	1447692660
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA KELLER MSC, LPC, CSAT

Provider Business Mailing Address
First Line	:	PO BOX 22409
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85734-2409
Country	:	US
Telephone Number	:	520-349-6016
Fax Number	:

Provider Business Practice Location Address
First Line	:	9500 N ORACLE RD
Second Line	:	SUITE 162J
City	:	TUCSON
State	:	AZ
Zip	:	85704-8523
Country	:	US
Telephone Number	:	520-349-6016
Fax Number	:

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

Provider Enumeration Date	:	07/30/2013
Last Update Date	:	06/07/2014

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