Individual
TRISTAN GLENN KELLER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
LISW
Contact information
Practice address
2025 E AZTEC AVE, GALLUP, NM 87301-4803
(505) 863-3828
(505) 863-6612
Mailing address
219 BOULDER RD, GALLUP, NM 87301-5795
(505) 863-3604
(505) 863-6612
Taxonomy
Speciality
Code
Description
License number
State
1041C0700X
Clinical Social Worker
Primary
I-05565
NM
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
50526
—
NM
Enumeration date
07/11/2006
Last updated
07/09/2007
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