Provider Demographics
NPI:1093906000
Name:KELLAM, TANYA (MSW)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:
Last Name:KELLAM
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1305 DEL NORTE RD STE 130
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93010-8366
Mailing Address - Country:US
Mailing Address - Phone:312-404-6278
Mailing Address - Fax:
Practice Address - Street 1:1305 DEL NORTE RD STE 130
Practice Address - Street 2:
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93010-8366
Practice Address - Country:US
Practice Address - Phone:312-404-6278
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-05
Last Update Date:2007-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker