Provider Demographics
NPI:1336412360
Name:KRISTIN M KEELER, S.C
Entity type:Organization
Organization Name:KRISTIN M KEELER, S.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KRISTIN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:KEELER
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:262-652-2365
Mailing Address - Street 1:4217 GREEN BAY RD
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53144-4518
Mailing Address - Country:US
Mailing Address - Phone:262-652-2365
Mailing Address - Fax:262-652-2071
Practice Address - Street 1:4217 GREEN BAY RD
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53144-4518
Practice Address - Country:US
Practice Address - Phone:262-652-2365
Practice Address - Fax:262-652-2071
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-22
Last Update Date:2012-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2277-057103TC0700X
IL071-006391103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty