Provider Demographics
NPI:1083704423
Name:KELLER, ELIZABETH COBURN (MS, LICSW)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:COBURN
Last Name:KELLER
Suffix:
Gender:F
Credentials:MS, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 DUDLEYVILLE RD
Mailing Address - Street 2:
Mailing Address - City:LEVERETT
Mailing Address - State:MA
Mailing Address - Zip Code:01054-9717
Mailing Address - Country:US
Mailing Address - Phone:413-210-8318
Mailing Address - Fax:
Practice Address - Street 1:25 MAIN ST
Practice Address - Street 2:SUITE #218
Practice Address - City:NORTHAMPTON
Practice Address - State:MA
Practice Address - Zip Code:01060-3109
Practice Address - Country:US
Practice Address - Phone:413-210-8318
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1113531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical