Provider Demographics
NPI:1124898150
Name:KELLER, CHARLIE (LPC)
Entity type:Individual
Prefix:MS
First Name:CHARLIE
Middle Name:
Last Name:KELLER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6333 DE ZAVALA RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78249-2115
Mailing Address - Country:US
Mailing Address - Phone:210-399-4838
Mailing Address - Fax:
Practice Address - Street 1:6333 DE ZAVALA RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78249-2115
Practice Address - Country:US
Practice Address - Phone:210-399-4838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-02
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX81810101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health