1699104059 NPI number — MS. SUSAN MARIE KELLER M.S., CFY-SLP

Table of content: MS. SUSAN MARIE KELLER M.S., CFY-SLP (NPI 1699104059)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699104059 NPI number — MS. SUSAN MARIE KELLER M.S., CFY-SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KELLER
Provider First Name:
SUSAN
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
M.S., CFY-SLP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1699104059
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/20/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3656 MALL DR.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EAU CLAIRE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54701
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-552-1035
Provider Business Mailing Address Fax Number:
715-552-4567

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3656 MULL DR.
Provider Second Line Business Practice Location Address:
DOVE HEALTHCARE - SOUTH
Provider Business Practice Location Address City Name:
EAU CLAIRE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54701
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-552-1035
Provider Business Practice Location Address Fax Number:
715-552-4567
Provider Enumeration Date:
11/06/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  3897-154 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com