=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770643579
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CATHERINE KELLER LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/11/2006
-----------------------------------------------------
Last Update Date | 04/20/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4 CHURCH ST.
-----------------------------------------------------
City | VINEYARD HAVEN
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02568
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-972-9071
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2195
-----------------------------------------------------
City | VINEYARD HAVEN
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02568-0917
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-972-9071
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 111002
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------