=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811168826
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KATHERINE TERESA KELLAM LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/18/2008
-----------------------------------------------------
Last Update Date | 02/28/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11835 HAZEL CIRCLE DR
-----------------------------------------------------
City | BRISTOW
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20136-2180
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-396-7076
-----------------------------------------------------
Fax | 703-361-4335
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13525 LELAND RD
-----------------------------------------------------
City | CENTREVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20120-2037
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-222-3558
-----------------------------------------------------
Fax | 703-803-7130
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 0904005806
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------