Provider Demographics
NPI:1053146399
Name:ELLERBE, KEELANI T
Entity type:Individual
Prefix:
First Name:KEELANI
Middle Name:T
Last Name:ELLERBE
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 1:2137 DEFENSE HWY STE 11
Mailing Address - Street 2:
Mailing Address - City:CROFTON
Mailing Address - State:MD
Mailing Address - Zip Code:21114-2420
Mailing Address - Country:US
Mailing Address - Phone:301-778-8744
Mailing Address - Fax:
Practice Address - Street 1:2137 DEFENSE HWY STE 11
Practice Address - Street 2:
Practice Address - City:CROFTON
Practice Address - State:MD
Practice Address - Zip Code:21114-2420
Practice Address - Country:US
Practice Address - Phone:301-778-8744
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-05
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDM05415225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist