Provider Demographics
NPI:1255385100
Name:KELLER, PATRICE ROLLAND
Entity type:Individual
Prefix:MRS
First Name:PATRICE
Middle Name:ROLLAND
Last Name:KELLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:733 DANTE STREET
Mailing Address - Street 2:SARA MAYO HEALTHCARE CENTER
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70118
Mailing Address - Country:US
Mailing Address - Phone:504-866-8819
Mailing Address - Fax:504-866-8836
Practice Address - Street 1:733 DANTE STREET
Practice Address - Street 2:SARA MAYO HEALTHCARE CENTER
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70118
Practice Address - Country:US
Practice Address - Phone:504-866-8819
Practice Address - Fax:504-866-8836
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA13981041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1142433Medicaid
LAP00176226OtherPALMETTO RR MEDICARE
LA1142433Medicaid
LA4C455C978Medicare ID - Type Unspecified