MEDICARE: ARIEL E KELLAM M.ED., BCBA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst	1-19-36675	CA
2	103K00000X	Behavior Analyst	1-19-36675	NH
3	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1538628755
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ARIEL E KELLAM M.ED., BCBA

Provider Business Mailing Address
First Line	:	9013 HORSE HERD DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76123-3072
Country	:	US
Telephone Number	:	714-366-9444
Fax Number	:

Provider Business Practice Location Address
First Line	:	9013 HORSE HERD DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76123-3072
Country	:	US
Telephone Number	:	714-366-9444
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/18/2019
Last Update Date	:	01/30/2024

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