Provider Demographics
NPI:1598146649
Name:KELLER, SAMANTHA
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:KELLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 HANOVER ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:LEBANON
Mailing Address - State:NH
Mailing Address - Zip Code:03766-1312
Mailing Address - Country:US
Mailing Address - Phone:603-448-0126
Mailing Address - Fax:
Practice Address - Street 1:85 MECHANIC ST
Practice Address - Street 2:SUITE 360
Practice Address - City:LEBANON
Practice Address - State:NH
Practice Address - Zip Code:03766-1537
Practice Address - Country:US
Practice Address - Phone:603-448-5610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-15
Last Update Date:2016-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
RE2534Medicare PIN