Provider Demographics
NPI:1699815100
Name:KELLEHER, JAMES A (PT)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:A
Last Name:KELLEHER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:MR
Other - First Name:JAMES
Other - Middle Name:A
Other - Last Name:KELLEHER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT
Mailing Address - Street 1:351 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:NJ
Mailing Address - Zip Code:08097-1345
Mailing Address - Country:US
Mailing Address - Phone:856-853-2623
Mailing Address - Fax:856-853-2747
Practice Address - Street 1:70 MANHEIM AVE
Practice Address - Street 2:SUITE 3
Practice Address - City:BRIDGETON
Practice Address - State:NJ
Practice Address - Zip Code:08302-2136
Practice Address - Country:US
Practice Address - Phone:856-455-9700
Practice Address - Fax:856-455-9791
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00876500225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ31-6704Medicare ID - Type Unspecified