Provider Demographics
NPI:1104254598
Name:MILLIE S. KELLEHER, LCSW
Entity type:Organization
Organization Name:MILLIE S. KELLEHER, LCSW
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:MASON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-548-8697
Mailing Address - Street 1:1090 FOUNDERS BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-6163
Mailing Address - Country:US
Mailing Address - Phone:706-548-8697
Mailing Address - Fax:706-548-8698
Practice Address - Street 1:1090 FOUNDERS BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-6163
Practice Address - Country:US
Practice Address - Phone:706-548-8697
Practice Address - Fax:706-548-8698
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-22
Last Update Date:2013-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0025361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty