Provider Demographics
NPI:1699238022
Name:KELLER, MEGAN LOIS (OTR/L)
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:LOIS
Last Name:KELLER
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 N LAKE SHORE DR APT 405
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-3401
Mailing Address - Country:US
Mailing Address - Phone:248-925-7374
Mailing Address - Fax:
Practice Address - Street 1:1219 W ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153-4046
Practice Address - Country:US
Practice Address - Phone:708-216-5300
Practice Address - Fax:708-531-7936
Is Sole Proprietor?:No
Enumeration Date:2019-04-11
Last Update Date:2019-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.012197225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist