Basic Information
| Provider Information | |||||||||
| NPI: | 1548700255 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KELLEHER | ||||||||
| FirstName: | KRISTEN | ||||||||
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| Credential: | ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 333 EARLE OVINGTON BLVD | ||||||||
| Address2: | SUITE 225 | ||||||||
| City: | UNIONDALE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115533610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5163212400 | ||||||||
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| Practice Location | |||||||||
| Address1: | 68 RIVER RD | ||||||||
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| City: | SUMMIT | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 079011450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9082770800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2017 | ||||||||
| LastUpdateDate: | 02/28/2017 | ||||||||
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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 | 246Z00000X | 001860 | NY | Y | Technologists, Technicians & Other Technical Service Providers | Specialist/Technologist, Other |
No ID Information.