| Doctor Name: | TRISTAN GLENN KELLER |
| NPI Number: | 1053346171 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | LISW |
| License Number: | I-05565 |
| Business Practice Address: | 2025 E Aztec Ave Gallup, NM - 873014803 |
| Business Phone Number: | 5058633828 |
| Business Fax Number: | 5058636612 |
| Mailing Address: | 219 Boulder Rd, GALLUP |
| State: | NM |
| Postal Code: | 873015795 |
| Phone Number: | 5058633604 |
| Fax Number: | 5058636612 |
| NPI Enumeration Date: | 07/11/2006 |
| NPI Last Update Date: | 07/09/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 1041C0700X |
| License Number: | I-05565 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | NM |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Social Worker |
| Taxonomy Specialization: | Clinical |
| Taxonomy Definition: | A social worker who holds a master |