Provider Demographics
NPI:1497498240
Name:KELLUM, SAMANTHA (RBT)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:KELLUM
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:146 S THOMAS ST STE C
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-5328
Mailing Address - Country:US
Mailing Address - Phone:662-840-0974
Mailing Address - Fax:662-840-0388
Practice Address - Street 1:146 S THOMAS ST STE C
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-5328
Practice Address - Country:US
Practice Address - Phone:662-840-0974
Practice Address - Fax:662-840-0388
Is Sole Proprietor?:No
Enumeration Date:2022-04-19
Last Update Date:2022-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician