Provider Demographics
NPI:1952004566
Name:KELLEHER, COLLEEN ANN
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:ANN
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 1:17335 PAGONIA RD STE 109
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-6011
Mailing Address - Country:US
Mailing Address - Phone:407-614-4299
Mailing Address - Fax:
Practice Address - Street 1:2105 HARTWOOD MARSH RD STE 7
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-5390
Practice Address - Country:US
Practice Address - Phone:407-720-5067
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-23
Last Update Date:2025-07-29
Deactivation Date:2023-03-23
Deactivation Code:
Reactivation Date:2023-04-06
Provider Licenses
StateLicense IDTaxonomies
106S00000X
FL103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician