Provider Demographics
NPI:1053065169
Name:THE PRACTICE OF AMANDA KELLER, LCSW, PLLC
Entity Type:Organization
Organization Name:THE PRACTICE OF AMANDA KELLER, LCSW, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER/CLINICIAN
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW-R
Authorized Official - Phone:518-906-9116
Mailing Address - Street 1:5 SOUTHSIDE DR STE 11-131
Mailing Address - Street 2:
Mailing Address - City:CLIFTON PARK
Mailing Address - State:NY
Mailing Address - Zip Code:12065-3870
Mailing Address - Country:US
Mailing Address - Phone:518-906-9116
Mailing Address - Fax:
Practice Address - Street 1:5 SOUTHSIDE DR STE 11-131
Practice Address - Street 2:
Practice Address - City:CLIFTON PARK
Practice Address - State:NY
Practice Address - Zip Code:12065-3870
Practice Address - Country:US
Practice Address - Phone:518-906-9116
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-08
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty