Provider Demographics
NPI:1992130298
Name:KELLER, SETH MICHAEL (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:SETH
Middle Name:MICHAEL
Last Name:KELLER
Suffix:
Gender:M
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:LISBON FALLS
Mailing Address - State:ME
Mailing Address - Zip Code:04252-1810
Mailing Address - Country:US
Mailing Address - Phone:207-423-1786
Mailing Address - Fax:
Practice Address - Street 1:75 W COMMERCIAL ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-4797
Practice Address - Country:US
Practice Address - Phone:207-874-1065
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-05
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEST2283235Z00000X
MESP2360235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist