Provider Demographics
NPI:1669869913
Name:KELLEHER, TRACY
Entity type:Individual
Prefix:
First Name:TRACY
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 1:72-4109 AWALUA PL
Mailing Address - Street 2:
Mailing Address - City:KAILUA KONA
Mailing Address - State:HI
Mailing Address - Zip Code:96740-8444
Mailing Address - Country:US
Mailing Address - Phone:305-393-9805
Mailing Address - Fax:
Practice Address - Street 1:210 WARD AVE
Practice Address - Street 2:SUITE 219B
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96814-4008
Practice Address - Country:US
Practice Address - Phone:808-380-4465
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-23
Last Update Date:2015-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst