MEDICARE: MS. CHARMAINE W KELLER ,LICSW,LCSW, CAP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	CAP 2177	FL
2	1041C0700X	Clinical Social Worker	SW7591	FL

General Provider Information

NPI Number	:	1417078064
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. CHARMAINE W KELLER ,LICSW,LCSW, CAP

Provider Business Mailing Address
First Line	:	15 PARK ST UNIT 101
Second Line	:
City	:	NEWPORT
State	:	NH
Zip	:	03773-8038
Country	:	US
Telephone Number	:	727-481-3581
Fax Number	:	603-413-4848

Provider Business Practice Location Address
First Line	:	24 OPERA HOUSE SQ # 409
Second Line	:
City	:	CLAREMONT
State	:	NH
Zip	:	03743-5408
Country	:	US
Telephone Number	:	727-481-3581
Fax Number	:	603-413-4848

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/02/2007
Last Update Date	:	01/06/2023

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