Provider Demographics
NPI:1699109355
Name:KELLER, TYLER
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:KELLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2401 NW 23RD ST
Mailing Address - Street 2:SUITE 76A, ATTN: G. BOHLEN
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73107-2442
Mailing Address - Country:US
Mailing Address - Phone:405-522-6695
Mailing Address - Fax:
Practice Address - Street 1:1200 NE 13TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73117-1022
Practice Address - Country:US
Practice Address - Phone:405-522-6695
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-29
Last Update Date:2013-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health