Provider Demographics
NPI:1326752544
Name:KELLER, NICOLE (LMSW)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:KELLER
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 FARMINGDALE ROAD
Mailing Address - Street 2:
Mailing Address - City:WEST BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11704
Mailing Address - Country:US
Mailing Address - Phone:631-512-4092
Mailing Address - Fax:
Practice Address - Street 1:22 BERGEN LN
Practice Address - Street 2:
Practice Address - City:BLUE POINT
Practice Address - State:NY
Practice Address - Zip Code:11715-2111
Practice Address - Country:US
Practice Address - Phone:631-513-2320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-11
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY118058-01104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker