Provider Demographics
NPI:1104499680
Name:KELLER, MEGAN (EDS)
Entity type:Individual
Prefix:MRS
First Name:MEGAN
Middle Name:
Last Name:KELLER
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:522 HARMONY DR
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471-4735
Mailing Address - Country:US
Mailing Address - Phone:503-804-3983
Mailing Address - Fax:
Practice Address - Street 1:522 HARMONY DR
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-4735
Practice Address - Country:US
Practice Address - Phone:503-804-3983
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-21
Last Update Date:2023-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS103TS0200X
CA170214308103TS0200X
ID7024103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool