Provider Demographics
NPI:1720429004
Name:KELLEHER, MELISSA A (LCSW)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:A
Last Name:KELLEHER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:761 MAIN AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:NORWALK
Mailing Address - State:CT
Mailing Address - Zip Code:06851-1080
Mailing Address - Country:US
Mailing Address - Phone:203-750-7400
Mailing Address - Fax:
Practice Address - Street 1:761 MAIN AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:NORWALK
Practice Address - State:CT
Practice Address - Zip Code:06851-1080
Practice Address - Country:US
Practice Address - Phone:203-750-7400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-15
Last Update Date:2015-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0083081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008308OtherLICENSE #