Provider Demographics
NPI:1063250280
Name:KELLEHER, ADELLE
Entity type:Individual
Prefix:
First Name:ADELLE
Middle Name:
Last Name:KELLEHER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4140 COLDSTREAM TER
Mailing Address - Street 2:
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-5412
Mailing Address - Country:US
Mailing Address - Phone:858-717-5515
Mailing Address - Fax:
Practice Address - Street 1:4140 COLDSTREAM TER
Practice Address - Street 2:
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-5412
Practice Address - Country:US
Practice Address - Phone:858-717-5515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-20
Last Update Date:2024-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA002737939253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care