Provider Demographics
NPI:1902146400
Name:KELLER, TRACY DIANE (SLP)
Entity Type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:DIANE
Last Name:KELLER
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2810 CREEK BEND DR
Mailing Address - Street 2:
Mailing Address - City:FRIENDSWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:77546-6038
Mailing Address - Country:US
Mailing Address - Phone:913-608-6617
Mailing Address - Fax:
Practice Address - Street 1:17045 EL CAMINO REAL STE 106
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77058-2623
Practice Address - Country:US
Practice Address - Phone:281-480-5648
Practice Address - Fax:281-480-5691
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-20
Last Update Date:2013-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX108100235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist