Provider Demographics
NPI:1699104059
Name:KELLER, SUSAN MARIE (MS, CFY-SLP)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:MARIE
Last Name:KELLER
Suffix:
Gender:F
Credentials:MS, CFY-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3656 MALL DR.
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701
Mailing Address - Country:US
Mailing Address - Phone:715-552-1035
Mailing Address - Fax:715-552-4567
Practice Address - Street 1:3656 MULL DR.
Practice Address - Street 2:DOVE HEALTHCARE - SOUTH
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701
Practice Address - Country:US
Practice Address - Phone:715-552-1035
Practice Address - Fax:715-552-4567
Is Sole Proprietor?:No
Enumeration Date:2013-11-06
Last Update Date:2014-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3897-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist