Provider Demographics
NPI:1447692660
Name:KELLER, LISA (MSC, LPC, CSAT)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:KELLER
Suffix:
Gender:F
Credentials:MSC, LPC, CSAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 22409
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85734-2409
Mailing Address - Country:US
Mailing Address - Phone:520-349-6016
Mailing Address - Fax:
Practice Address - Street 1:9500 N ORACLE RD
Practice Address - Street 2:SUITE 162J
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85704-8523
Practice Address - Country:US
Practice Address - Phone:520-349-6016
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-30
Last Update Date:2014-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-14464101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZLPC-14464OtherLICENSED PROFESSIONAL COUNSELOR