MEDICARE: TANYA A KELLER M.S CCC-SLP ED.S

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	235Z00000X	Speech-Language Pathologist	6650	MA
2	235Z00000X	Speech-Language Pathologist	SP27018	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	SP0175	OTHER	MA	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1780809822
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TANYA A KELLER M.S CCC-SLP ED.S

Provider Business Mailing Address
First Line	:	4735 BANCROFT ST APT 6
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92116-1667
Country	:	US
Telephone Number	:	617-780-5193
Fax Number	:	619-362-9930

Provider Business Practice Location Address
First Line	:	4735 BANCROFT ST APT 6
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92116-1667
Country	:	US
Telephone Number	:	617-780-5193
Fax Number	:	619-362-9930

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

Provider Enumeration Date	:	04/16/2007
Last Update Date	:	06/08/2023

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Directions to “ TANYA A KELLER M.S CCC-SLP ED.S” Practice Location

Language	Start Address	Practice Location

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