Provider Demographics
NPI:1629687306
Name:KELLEHER, KIMBERLY
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:KELLEHER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 38535
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21231-8535
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9 NEWBURG AVE STE 102
Practice Address - Street 2:
Practice Address - City:CATONSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21228-5157
Practice Address - Country:US
Practice Address - Phone:443-840-7862
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-28
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15654101YP2500X
CA106H00000X
MDLC14859101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist