Provider Demographics
NPI:1780335042
Name:KELLER, VIOLINA
Entity type:Individual
Prefix:
First Name:VIOLINA
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 1:133 SENORA PL
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-1582
Mailing Address - Country:US
Mailing Address - Phone:478-731-0309
Mailing Address - Fax:
Practice Address - Street 1:2080 INGLESIDE AVE
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31204-2028
Practice Address - Country:US
Practice Address - Phone:478-227-6607
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-18
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty