Provider Demographics
NPI:1104944511
Name:KELLEHER, MIDA LILA-MARIE (LMT)
Entity type:Individual
Prefix:MS
First Name:MIDA
Middle Name:LILA-MARIE
Last Name:KELLEHER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2208 WOODBURY RD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-3059
Mailing Address - Country:US
Mailing Address - Phone:321-302-4860
Mailing Address - Fax:
Practice Address - Street 1:2208 WOODBURY RD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-3059
Practice Address - Country:US
Practice Address - Phone:321-302-4860
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA47456225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty