Healthcare Provider Details

I. General information

NPI: 1538634423
Provider Name (Legal Business Name): THOMAS B. KELEM LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2018
Last Update Date: 10/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 E WASHINGTON BLVD
CRESCENT CITY CA
95531-8160
US

IV. Provider business mailing address

670 9TH ST STE 203
ARCATA CA
95521-6249
US

V. Phone/Fax

Practice location:
  • Phone: 707-465-6925
  • Fax: 707-465-6070
Mailing address:
  • Phone: 707-826-8633
  • Fax: 707-826-8638

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number030406
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: