Provider Demographics
NPI:1124197405
Name:KELLAM, HEATHER LYNNE (LCSWC)
Entity Type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:LYNNE
Last Name:KELLAM
Suffix:
Gender:F
Credentials:LCSWC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2336 GODDARD PKWY
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21801-1126
Mailing Address - Country:US
Mailing Address - Phone:410-334-6961
Mailing Address - Fax:410-334-6960
Practice Address - Street 1:2336 GODDARD PARKWAY
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21801
Practice Address - Country:US
Practice Address - Phone:410-334-6961
Practice Address - Fax:410-334-6362
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2011-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD132171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD522156095OtherAMERICAN PSYCH SYSTEM
MD0035OtherCAREFIRST BCBS-FED-PIN
MD522156095OtherNCPPO
MD893100-01OtherCAREFIRST BCBS PIN
MDLM49EAOtherCAREFIRST BCBS GROUP
R968OtherCAREFIRST FEDERAL GROUP
MD609550001Medicaid
MD259147000OtherMAGELLAN GROUP
517251OtherUHC MAMSI GROUP
MD0035OtherCAREFIRST BCBS-FED-PIN
MDLM49EAOtherCAREFIRST BCBS GROUP