Provider Demographics
NPI:1548550346
Name:KELLEHER, IAN M (LICSW)
Entity type:Individual
Prefix:
First Name:IAN
Middle Name:M
Last Name:KELLEHER
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 ALFRED ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WOBURN
Mailing Address - State:MA
Mailing Address - Zip Code:01801-1972
Mailing Address - Country:US
Mailing Address - Phone:781-646-0500
Mailing Address - Fax:
Practice Address - Street 1:12 ALFRED ST
Practice Address - Street 2:SUITE 200
Practice Address - City:WOBURN
Practice Address - State:MA
Practice Address - Zip Code:01801-1972
Practice Address - Country:US
Practice Address - Phone:781-646-0500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-13
Last Update Date:2011-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1160511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical