Provider Demographics
NPI:1366476335
Name:KELLEHER, HEIDI LAURA (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:LAURA
Last Name:KELLEHER
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:873 TURNPIKE ST
Mailing Address - Street 2:
Mailing Address - City:NORTH ANDOVER
Mailing Address - State:MA
Mailing Address - Zip Code:01845-6152
Mailing Address - Country:US
Mailing Address - Phone:978-688-8004
Mailing Address - Fax:978-686-8554
Practice Address - Street 1:873 TURNPIKE ST
Practice Address - Street 2:
Practice Address - City:NORTH ANDOVER
Practice Address - State:MA
Practice Address - Zip Code:01845-6152
Practice Address - Country:US
Practice Address - Phone:978-688-8004
Practice Address - Fax:978-686-8554
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2013-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA176641363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MANP458202Medicare PIN