Individual
DR. DOMINIK LIA KELLER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PHD
Contact information
Practice address
5915 GETWELL RD BLDG B, SOUTHAVEN, MS 38672-6455
(662) 349-2979
Mailing address
5915 GETWELL RD BLDG B, SOUTHAVEN, MS 38672-6455
(662) 349-2979
Taxonomy
Speciality
Code
Description
License number
State
103TS0200X
School Psychologist
Primary
621149
MS
106S00000X
Behavior Technician
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
110026265E
—
MA
05
—
200000200
—
MS
Enumeration date
03/29/2022
Last updated
12/15/2022
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