Provider Demographics
NPI:1285281956
Name:KELLER, CONNIE V (MHS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:V
Last Name:KELLER
Suffix:
Gender:F
Credentials:MHS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5113 N TROOST AVE
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64118-5312
Mailing Address - Country:US
Mailing Address - Phone:816-844-1017
Mailing Address - Fax:
Practice Address - Street 1:201 N FOREST AVE
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64050-2696
Practice Address - Country:US
Practice Address - Phone:816-521-5485
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-19
Last Update Date:2019-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO304838235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist