Provider Demographics
NPI:1043254089
Name:KELLER, MARY MONACO (EDD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:MONACO
Last Name:KELLER
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 OAK PL
Mailing Address - Street 2:
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:NY
Mailing Address - Zip Code:11968-1525
Mailing Address - Country:US
Mailing Address - Phone:631-283-3296
Mailing Address - Fax:631-283-3296
Practice Address - Street 1:55 POST AVE
Practice Address - Street 2:SUITE #205
Practice Address - City:WESTBURY
Practice Address - State:NY
Practice Address - Zip Code:11590-4361
Practice Address - Country:US
Practice Address - Phone:631-921-8561
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-16
Last Update Date:2010-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015524103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical