MEDICARE: MS. THERESE MARY KELLEHER CRC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	00012423	IL

General Provider Information

NPI Number	:	1407014624
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. THERESE MARY KELLEHER CRC

Provider Business Mailing Address
First Line	:	30 LAKE ST APT 10E
Second Line	:
City	:	WHITE PLAINS
State	:	NY
Zip	:	10603-4016
Country	:	US
Telephone Number	:	914-428-9845
Fax Number	:

Provider Business Practice Location Address
First Line	:	30 LAKE ST APT 10E
Second Line	:
City	:	WHITE PLAINS
State	:	NY
Zip	:	10603-4016
Country	:	US
Telephone Number	:	914-428-9845
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/23/2008
Last Update Date	:	05/23/2008

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