Provider Demographics
NPI:1053346171
Name:KELLER, TRISTAN GLENN (LISW)
Entity type:Individual
Prefix:
First Name:TRISTAN
Middle Name:GLENN
Last Name:KELLER
Suffix:
Gender:M
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:219 BOULDER RD
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-5795
Mailing Address - Country:US
Mailing Address - Phone:505-863-3604
Mailing Address - Fax:505-863-6612
Practice Address - Street 1:2025 E AZTEC AVE
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-4803
Practice Address - Country:US
Practice Address - Phone:505-863-3828
Practice Address - Fax:505-863-6612
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-055651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM50526Medicaid