Healthcare Provider Details

I. General information

NPI: 1982992889
Provider Name (Legal Business Name): WENDY KELLER, LCSW, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2011
Last Update Date: 06/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

633 GIDNEY AVE SUITE 2
NEWBURGH NY
12550
US

IV. Provider business mailing address

633 GIDNEY AVE STE 4-6
NEWBURGH NY
12550-2800
US

V. Phone/Fax

Practice location:
  • Phone: 845-242-8375
  • Fax: 866-619-5710
Mailing address:
  • Phone: 845-242-8375
  • Fax: 866-619-5710

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberR055693
License Number StateNY

VIII. Authorized Official

Name: WENDY KELLER
Title or Position: PRESIDENT
Credential: LCSW
Phone: 845-242-8375