Provider Demographics
NPI:1316131477
Name:KELLER, SHAUNA MARIE (PSYD)
Entity type:Individual
Prefix:DR
First Name:SHAUNA
Middle Name:MARIE
Last Name:KELLER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2084
Mailing Address - Street 2:
Mailing Address - City:SEASIDE
Mailing Address - State:CA
Mailing Address - Zip Code:93955-2084
Mailing Address - Country:US
Mailing Address - Phone:650-302-6543
Mailing Address - Fax:
Practice Address - Street 1:HIGHWAY 101 NORTH
Practice Address - Street 2:CORRECTIONAL TRAINING FACILITY
Practice Address - City:SOLEDAD
Practice Address - State:CA
Practice Address - Zip Code:93960
Practice Address - Country:US
Practice Address - Phone:650-302-6543
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-31
Last Update Date:2015-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4454103TC0700X
CAPSY23931173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical