Provider Demographics
NPI:1962742569
Name:KELLER, MATTHEW RYAN (LPC)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:RYAN
Last Name:KELLER
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1815 PLEASANT GROVE RD
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-7870
Mailing Address - Country:US
Mailing Address - Phone:870-933-6886
Mailing Address - Fax:870-933-9395
Practice Address - Street 1:75 HWY 62/4 12
Practice Address - Street 2:SUITE J
Practice Address - City:ASH FLAT
Practice Address - State:AR
Practice Address - Zip Code:72513-9629
Practice Address - Country:US
Practice Address - Phone:870-994-7060
Practice Address - Fax:870-994-7063
Is Sole Proprietor?:No
Enumeration Date:2013-02-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARP1511123101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR191202795Medicaid