MEDICARE: THERESA KELLAM, PH.D.

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	251S00000X	Community/Behavioral Health Agency	32518	TX

General Provider Information

NPI Number	:	1205248150
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THERESA KELLAM, PH.D.

Provider Business Mailing Address
First Line	:	2201 DOTTIE LYNN PKWY
Second Line	:	SUITE 127
City	:	FORT WORTH
State	:	TX
Zip	:	76120-4432
Country	:	US
Telephone Number	:	817-313-7899
Fax Number	:

Provider Business Practice Location Address
First Line	:	2201 DOTTIE LYNN PKWY
Second Line	:	SUITE 127
City	:	FORT WORTH
State	:	TX
Zip	:	76120-4432
Country	:	US
Telephone Number	:	817-313-7899
Fax Number	:

Authorized Official
Title or Position	:	OWNER/PSYCHOLOGIST
Name	:	DR. THERESA KELLAM
Credential	:	PH.D.
Telephone Number	:	817-313-7899

Provider Enumeration Date	:	05/27/2014
Last Update Date	:	05/27/2014

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