Healthcare Provider Details

I. General information

NPI: 1124197405
Provider Name (Legal Business Name): HEATHER LYNNE KELLAM LCSWC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 12/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2336 GODDARD PARKWAY
SALISBURY MD
21801
US

IV. Provider business mailing address

2336 GODDARD PKWY
SALISBURY MD
21801-1126
US

V. Phone/Fax

Practice location:
  • Phone: 410-334-6961
  • Fax: 410-334-6362
Mailing address:
  • Phone: 410-334-6961
  • Fax: 410-334-6960

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number13217
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: