Provider Demographics
NPI:1861032799
Name:KELLAHAN, RICHARD HADDON
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:HADDON
Last Name:KELLAHAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3930 CASTLEMAN AVE # 1F
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-3739
Mailing Address - Country:US
Mailing Address - Phone:843-283-6252
Mailing Address - Fax:
Practice Address - Street 1:5285 HIGHWAY N STE 103
Practice Address - Street 2:
Practice Address - City:COTTLEVILLE
Practice Address - State:MO
Practice Address - Zip Code:63304-7733
Practice Address - Country:US
Practice Address - Phone:314-529-1713
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-08
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019027875101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional