Provider Demographics
NPI:1629685888
Name:KELLEHER, EVELYN CASTILLO
Entity Type:Individual
Prefix:
First Name:EVELYN
Middle Name:CASTILLO
Last Name:KELLEHER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:EVELYN
Other - Middle Name:CASTILLO
Other - Last Name:FULGAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1709 BRAGAW ST
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-3436
Mailing Address - Country:US
Mailing Address - Phone:907-562-5340
Mailing Address - Fax:
Practice Address - Street 1:1709 BRAGAW ST
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-3436
Practice Address - Country:US
Practice Address - Phone:907-562-5340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-30
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health