MEDICARE: MS. REBECCA ELIZABETH KELLERMAN

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

General Provider Information

NPI Number	:	1922327451
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. REBECCA ELIZABETH KELLERMAN

Provider Business Mailing Address
First Line	:	158 WILSON RD
Second Line	:	P.O. BOX 447
City	:	SPARROW BUSH
State	:	NY
Zip	:	12780-5440
Country	:	US
Telephone Number	:	845-858-8374
Fax Number	:

Provider Business Practice Location Address
First Line	:	158 WILSON RD
Second Line	:
City	:	SPARROW BUSH
State	:	NY
Zip	:	12780-5440
Country	:	US
Telephone Number	:	845-858-8374
Fax Number	:

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

Provider Enumeration Date	:	05/24/2010
Last Update Date	:	05/24/2010

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