Provider Demographics
NPI:1295798114
Name:KELLEHER, MARY ELIZABETH (LICSW)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ELIZABETH
Last Name:KELLEHER
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:MRS
Other - First Name:MARY
Other - Middle Name:BRYAN
Other - Last Name:KELLEHER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LICSW
Mailing Address - Street 1:19 MAYFAIR ST
Mailing Address - Street 2:
Mailing Address - City:NORWOOD
Mailing Address - State:MA
Mailing Address - Zip Code:02062-1201
Mailing Address - Country:US
Mailing Address - Phone:781-762-6335
Mailing Address - Fax:
Practice Address - Street 1:58 OLD COLONY AVE
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02127-2406
Practice Address - Country:US
Practice Address - Phone:617-268-1700
Practice Address - Fax:617-268-1991
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2014-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1054381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAKEP23687OtherSOCIAL WORKER