Provider Demographics
NPI:1063579183
Name:KEELER, MARK H (PHD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:H
Last Name:KEELER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:259 ROCK ST APT A10
Mailing Address - Street 2:
Mailing Address - City:NORWOOD
Mailing Address - State:MA
Mailing Address - Zip Code:02062-4977
Mailing Address - Country:US
Mailing Address - Phone:781-769-9689
Mailing Address - Fax:
Practice Address - Street 1:687 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:NEEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02494-2232
Practice Address - Country:US
Practice Address - Phone:617-254-3800
Practice Address - Fax:617-779-1482
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2019-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7092103TC0700X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW06000OtherBLUE CROSS-BLUE SHIELD
MA110022270AMedicaid
MA0500054Medicaid
W50632Medicare ID - Type Unspecified
S35576Medicare UPIN