Healthcare Provider Details

I. General information

NPI: 1619094083
Provider Name (Legal Business Name): SARAH KELLETER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SARAH FOURNIER LCSW

II. Dates (important events)

Enumeration Date: 03/23/2007
Last Update Date: 12/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

173 LINCOLNVILLE AVE C/O RSU 20
BELFAST ME
04915
US

IV. Provider business mailing address

173 LINCOLNVILLE AVE C/O RSU 20
BELFAST ME
04915
US

V. Phone/Fax

Practice location:
  • Phone: 207-930-2019
  • Fax:
Mailing address:
  • Phone: 207-338-3320
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC5141
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: