Provider Demographics
NPI:1568535235
Name:KELLERMAN, M SHAWN (LMHC SAP MAC CAP CCJ)
Entity Type:Individual
Prefix:MR
First Name:M
Middle Name:SHAWN
Last Name:KELLERMAN
Suffix:
Gender:M
Credentials:LMHC SAP MAC CAP CCJ
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 16524
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33733-6524
Mailing Address - Country:US
Mailing Address - Phone:727-580-9117
Mailing Address - Fax:813-961-9787
Practice Address - Street 1:3110 1ST AVE N 2ND FLOOR SUITE 6W
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33733-6524
Practice Address - Country:US
Practice Address - Phone:727-580-9117
Practice Address - Fax:813-961-9787
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1533CAT1533101YA0400X
FLMH3987101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health