Provider Demographics
NPI:1306954599
Name:KELLER, EARLENE A (LCSW)
Entity type:Individual
Prefix:
First Name:EARLENE
Middle Name:A
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:PO BOX 162
Mailing Address - Street 2:
Mailing Address - City:STANDARD
Mailing Address - State:CA
Mailing Address - Zip Code:95373
Mailing Address - Country:US
Mailing Address - Phone:209-532-8517
Mailing Address - Fax:209-532-3929
Practice Address - Street 1:101 S FOREST RD
Practice Address - Street 2:
Practice Address - City:SONORA
Practice Address - State:CA
Practice Address - Zip Code:95370
Practice Address - Country:US
Practice Address - Phone:209-532-8517
Practice Address - Fax:209-532-3929
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-28
Last Update Date:2020-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS143881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACSW143880Medicaid
CACSW143880Medicaid