MEDICARE: LUMA PSYCHOLOGY PLLC

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

General Provider Information

NPI Number	:	1306481205
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LUMA PSYCHOLOGY PLLC

Provider Business Mailing Address
First Line	:	2201 DOTTIE LYNN PKWY STE 127
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76120-4435
Country	:	US
Telephone Number	:	817-313-7899
Fax Number	:

Provider Business Practice Location Address
First Line	:	2201 DOTTIE LYNN PKWY STE 127
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76120-4435
Country	:	US
Telephone Number	:	817-313-7899
Fax Number	:

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

Provider Enumeration Date	:	11/14/2019
Last Update Date	:	11/14/2019

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