Provider Demographics
NPI:1689102501
Name:KELLER, KENYA
Entity type:Individual
Prefix:
First Name:KENYA
Middle Name:
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 1:1740 WILSHIRE AVE
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43614-3654
Mailing Address - Country:US
Mailing Address - Phone:419-309-9305
Mailing Address - Fax:
Practice Address - Street 1:5648 MAIN ST
Practice Address - Street 2:
Practice Address - City:SYLVANIA
Practice Address - State:OH
Practice Address - Zip Code:43560-3940
Practice Address - Country:US
Practice Address - Phone:419-309-9305
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-24
Last Update Date:2025-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
247200000X
OHC.2203931103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other