Provider Demographics
NPI:1619428984
Name:KILLEEN, KATHLEEN ANN (LICSW, MLADC, CAADC)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:ANN
Last Name:KILLEEN
Suffix:
Gender:F
Credentials:LICSW, MLADC, CAADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:173 MIDDLE ST
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:NH
Mailing Address - Zip Code:03584-3508
Mailing Address - Country:US
Mailing Address - Phone:603-788-4911
Mailing Address - Fax:
Practice Address - Street 1:173 MIDDLE ST
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:NH
Practice Address - Zip Code:03584-3508
Practice Address - Country:US
Practice Address - Phone:603-788-4911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-20
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC7484101YA0400X
PA9733101YA0400X
DE1637101YA0400X
NH1201101YA0400X
VT1510134098101YA0400X
PASW123039104100000X
MD17282104100000X
NJ44SL05713500104100000X
DEQ1-00012551041C0700X
VT08901342551041C0700X
MELC188751041C0700X
NH22481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3119205Medicaid
VT6701953Medicaid