Provider Demographics
NPI:1831379148
Name:KELLERMAN, DANETTE R (CADC II,)
Entity type:Individual
Prefix:MS
First Name:DANETTE
Middle Name:R
Last Name:KELLERMAN
Suffix:
Gender:F
Credentials:CADC II,
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 6310
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:CA
Mailing Address - Zip Code:95502-6310
Mailing Address - Country:US
Mailing Address - Phone:707-443-0514
Mailing Address - Fax:707-442-1191
Practice Address - Street 1:1024 N ST
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501-2047
Practice Address - Country:US
Practice Address - Phone:707-269-9566
Practice Address - Fax:707-442-1191
Is Sole Proprietor?:No
Enumeration Date:2007-11-05
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA6320611101YA0400X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA011680315OtherCCAPP