Provider Demographics
NPI:1922302983
Name:KELLEHER, LISA J (LMFT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:J
Last Name:KELLEHER
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3075 ADELINE ST
Mailing Address - Street 2:SUITE 120
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94703-2576
Mailing Address - Country:US
Mailing Address - Phone:510-848-1112
Mailing Address - Fax:
Practice Address - Street 1:3075 ADELINE ST
Practice Address - Street 2:SUITE 120
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94703-2576
Practice Address - Country:US
Practice Address - Phone:510-848-1112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-05
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC92790106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist