MEDICARE: MS. CARLENE RAE KELLER LMHP

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	101Y00000X	Counselor	1561	NE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	84846	OTHER	NE	BLUE CROSS BLUE SHIELD NE

General Provider Information

NPI Number	:	1902808579
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. CARLENE RAE KELLER LMHP

Provider Business Mailing Address
First Line	:	907 WEST L STREET
Second Line	:	CARLENE KELLER, LMHP COUNSELING SERVICES
City	:	MC COOK
State	:	NE
Zip	:	69001-3537
Country	:	US
Telephone Number	:	308-345-7062
Fax Number	:	308-345-7062

Provider Business Practice Location Address
First Line	:	907 WEST L STREET
Second Line	:	CARLENE KELLER, LMHP COUNSELING SERVICES
City	:	MC COOK
State	:	NE
Zip	:	69001-3537
Country	:	US
Telephone Number	:	308-345-7062
Fax Number	:	308-345-7062

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

Provider Enumeration Date	:	08/12/2005
Last Update Date	:	07/08/2007

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