Healthcare Provider Details

I. General information

NPI: 1649218439
Provider Name (Legal Business Name): KAMALA JEAN KELTON LCMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 S MAIN ST BOX 4
WATERBURY VT
05676-1556
US

IV. Provider business mailing address

55 S MAIN ST BOX 4
WATERBURY VT
05676-1556
US

V. Phone/Fax

Practice location:
  • Phone: 802-244-7937
  • Fax: 802-244-7937
Mailing address:
  • Phone: 802-244-7937
  • Fax: 802-244-7937

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number068-0000359
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: