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General NPI Number Information
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NPI Number | 1295798114
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Entity Type | Individual
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Provider Name | MARY ELIZABETH KELLEHER LICSW
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Gender | Female
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Dates
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Enumeration Date | 04/11/2006
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Last Update Date | 03/25/2014
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Provider Practice Location Address
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Address Line | 58 OLD COLONY AVE
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City | SOUTH BOSTON
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State | MA
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Zip | 02127-2406
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Country | US
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Telephone | 617-268-1700
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Fax | 617-268-1991
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Provider Business Mailing Address
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Address Line | 19 MAYFAIR ST
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City | NORWOOD
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State | MA
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Zip | 02062-1201
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Country | US
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Telephone | 781-762-6335
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 105438
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License Number State | MA
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