Provider Demographics
NPI:1619227410
Name:KELLEHER, BRENDA (LCSW, LICSW)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:KELLEHER
Suffix:
Gender:F
Credentials:LCSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 MAINE ST STE A-291
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:ME
Mailing Address - Zip Code:04011-2098
Mailing Address - Country:US
Mailing Address - Phone:207-319-9005
Mailing Address - Fax:
Practice Address - Street 1:20860 N TATUM BLVD STE 300
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85050-4283
Practice Address - Country:US
Practice Address - Phone:207-319-9005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-19
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical