Provider Demographics
NPI:1417078064
Name:KELLER, CHARMAINE W (,LICSW,LCSW, CAP)
Entity Type:Individual
Prefix:MS
First Name:CHARMAINE
Middle Name:W
Last Name:KELLER
Suffix:
Gender:F
Credentials:,LICSW,LCSW, CAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 PARK ST UNIT 101
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:NH
Mailing Address - Zip Code:03773-8038
Mailing Address - Country:US
Mailing Address - Phone:727-481-3581
Mailing Address - Fax:603-413-4848
Practice Address - Street 1:24 OPERA HOUSE SQ # 409
Practice Address - Street 2:
Practice Address - City:CLAREMONT
Practice Address - State:NH
Practice Address - Zip Code:03743-5408
Practice Address - Country:US
Practice Address - Phone:727-481-3581
Practice Address - Fax:603-413-4848
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2023-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCAP 2177101YA0400X
FLSW75911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)