Healthcare Provider Details

I. General information

NPI: 1386241156
Provider Name (Legal Business Name): PAMELA SUE KELLERMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2020
Last Update Date: 08/28/2026
Certification Date: 08/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

57 BEDFORD ST STE 105
LEXINGTON MA
02420-4550
US

IV. Provider business mailing address

48 DEXTER AVE
WATERTOWN MA
02472-4107
US

V. Phone/Fax

Practice location:
  • Phone: 856-807-5330
  • Fax:
Mailing address:
  • Phone: 603-998-0920
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: