MEDICARE: DR. THERESA KELLAM PSYCHOLOGIST

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	103T00000X	Psychologist	32518	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	32518	OTHER	TX	PSYCHOLOGIST LICENSE

General Provider Information

NPI Number	:	1841271772
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THERESA KELLAM PSYCHOLOGIST

Provider Business Mailing Address
First Line	:	2201 DOTTIE LYNN PARKWAY
Second Line	:	SUITE 127
City	:	FORT WORTH
State	:	TX
Zip	:	76120
Country	:	US
Telephone Number	:	817-313-7899
Fax Number	:	817-303-7278

Provider Business Practice Location Address
First Line	:	2201 DOTTIE LYNN PARKWAY
Second Line	:	SUITE 127
City	:	FORT WORTH
State	:	TX
Zip	:	76120
Country	:	US
Telephone Number	:	817-313-7899
Fax Number	:	817-303-7278

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

Provider Enumeration Date	:	11/08/2005
Last Update Date	:	08/13/2009

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