Provider Demographics
NPI:1922371285
Name:KELLER, LAURA BETH
Entity Type:Individual
Prefix:MS
First Name:LAURA
Middle Name:BETH
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 1:53 GIBSON RD
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:NY
Mailing Address - Zip Code:10924-6709
Mailing Address - Country:US
Mailing Address - Phone:845-291-0200
Mailing Address - Fax:845-291-0279
Practice Address - Street 1:53 GIBSON RD
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:NY
Practice Address - Zip Code:10924-6709
Practice Address - Country:US
Practice Address - Phone:845-291-0200
Practice Address - Fax:845-291-0279
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-17
Last Update Date:2012-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY04772711041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool