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NPI Code Detail

MEDICARE: BRENDA KELLEHER LCSW, LICSW

MEDICARE: BRENDA KELLEHER LCSW, LICSW
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
11041C0700XClinical Social Worker

General Provider Information

NPI Number : 1619227410
Entity Type Code : Individual
Provider Name (Legal Business Name) : BRENDA KELLEHER LCSW, LICSW
Provider Business Mailing Address
First Line : 135 MAINE ST STE A-291
Second Line :
City : BRUNSWICK
State : ME
Zip : 04011-2098
Country : US
Telephone Number : 207-319-9005
Fax Number :
Provider Business Practice Location Address
First Line : 20860 N TATUM BLVD STE 300
Second Line :
City : PHOENIX
State : AZ
Zip : 85050-4283
Country : US
Telephone Number : 207-319-9005
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/19/2012
Last Update Date : 02/08/2023

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