Provider Demographics
NPI:1083834485
Name:KELLEHER, KATHLEEN ANN (PT)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:ANN
Last Name:KELLEHER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48 JOHNSON HTS
Mailing Address - Street 2:
Mailing Address - City:WATERVILLE
Mailing Address - State:ME
Mailing Address - Zip Code:04901-4907
Mailing Address - Country:US
Mailing Address - Phone:207-873-1705
Mailing Address - Fax:
Practice Address - Street 1:30 CHASE AVE
Practice Address - Street 2:EDMUND ERVIN PEDIATRIC CENTER
Practice Address - City:WATERVILLE
Practice Address - State:ME
Practice Address - Zip Code:04901-4624
Practice Address - Country:US
Practice Address - Phone:207-872-4390
Practice Address - Fax:207-872-4294
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT982225100000X, 2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Not Answered2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEPT982OtherPHYSICAL THERAPY LICENSE