Provider Demographics
NPI:1467534925
Name:KELLER, WENDY SUE (LCSW)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:SUE
Last Name:KELLER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:633 GIDNEY AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:NEWBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12550-2805
Mailing Address - Country:US
Mailing Address - Phone:845-242-8375
Mailing Address - Fax:866-619-5710
Practice Address - Street 1:633 GIDNEY AVE STE 2
Practice Address - Street 2:
Practice Address - City:NEWBURGH
Practice Address - State:NY
Practice Address - Zip Code:12550-2805
Practice Address - Country:US
Practice Address - Phone:845-242-8375
Practice Address - Fax:866-619-5710
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR055693-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY400585OtherMVP PROVIDER
NY400585OtherMVP PROVIDER