MEDICARE: TAELOR KELLUM

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	106S00000X	Behavior Technician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1346895034
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAELOR KELLUM

Provider Business Mailing Address
First Line	:	115 NW 21ST ST
Second Line	:
City	:	GAINESVILLE
State	:	FL
Zip	:	32603-1728
Country	:	US
Telephone Number	:	423-503-7615
Fax Number	:

Provider Business Practice Location Address
First Line	:	1000 NE 16TH AVE BLDG D
Second Line	:
City	:	GAINESVILLE
State	:	FL
Zip	:	32601-4541
Country	:	US
Telephone Number	:	352-332-8588
Fax Number	:	352-332-8589

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/08/2019
Last Update Date	:	08/08/2019

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Directions to “ TAELOR KELLUM ” Practice Location

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