Provider Demographics
NPI:1073057246
Name:KELLEHER, VICTORIA
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:KELLEHER
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 1:41-611 INOAOLE ST
Mailing Address - Street 2:
Mailing Address - City:WAIMANALO
Mailing Address - State:HI
Mailing Address - Zip Code:96795-1211
Mailing Address - Country:US
Mailing Address - Phone:808-892-4059
Mailing Address - Fax:
Practice Address - Street 1:41-611 INOAOLE ST
Practice Address - Street 2:
Practice Address - City:WAIMANALO
Practice Address - State:HI
Practice Address - Zip Code:96795-1211
Practice Address - Country:US
Practice Address - Phone:808-892-4059
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-07
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1-20-43923103K00000X
HIRBT-16-26569106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician