Provider Demographics
NPI:1124914775
Name:KELLER, JOSHUA TYLER
Entity type:Individual
Prefix:
First Name:JOSHUA
Middle Name:TYLER
Last Name:KELLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2146 CAMP CREEK CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:MOORESBORO
Mailing Address - State:NC
Mailing Address - Zip Code:28114-9719
Mailing Address - Country:US
Mailing Address - Phone:910-333-2919
Mailing Address - Fax:
Practice Address - Street 1:2146 CAMP CREEK CHURCH RD
Practice Address - Street 2:
Practice Address - City:MOORESBORO
Practice Address - State:NC
Practice Address - Zip Code:28114-9719
Practice Address - Country:US
Practice Address - Phone:910-333-2919
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-17
Last Update Date:2025-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCBACB1185642106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician