Provider Demographics
NPI:1518615046
Name:KELLER, DIANE M
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:M
Last Name:KELLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 QUAIL FOREST BLVD APT 605
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34105-5593
Mailing Address - Country:US
Mailing Address - Phone:317-400-1345
Mailing Address - Fax:
Practice Address - Street 1:420 QUAIL FOREST BLVD APT 605
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34105-5593
Practice Address - Country:US
Practice Address - Phone:317-400-1345
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-14
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSS1638103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool