Basic Information
| Provider Information | |||||||||
| NPI: | 1083834485 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLEHER | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 48 JOHNSON HTS | ||||||||
| Address2: | |||||||||
| City: | WATERVILLE | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049014907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078731705 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 30 CHASE AVE | ||||||||
| Address2: | EDMUND ERVIN PEDIATRIC CENTER | ||||||||
| City: | WATERVILLE | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049014624 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078724390 | ||||||||
| FaxNumber: | 2078724294 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT982 | ME | X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 2251P0200X | PT982 | ME | X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | PT982 | 01 | ME | PHYSICAL THERAPY LICENSE | OTHER |