Provider Demographics
NPI:1518679307
Name:BYRON KELLAM & ASSOCIATES, INC
Entity Type:Organization
Organization Name:BYRON KELLAM & ASSOCIATES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BYRON
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLAM
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, CPCS
Authorized Official - Phone:470-213-3568
Mailing Address - Street 1:3292 THORNECREEK DR
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135-8124
Mailing Address - Country:US
Mailing Address - Phone:470-213-3568
Mailing Address - Fax:770-577-2887
Practice Address - Street 1:4751 BEST RD STE 400T
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30337-5609
Practice Address - Country:US
Practice Address - Phone:470-213-3568
Practice Address - Fax:770-577-2887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-23
Last Update Date:2022-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchoolGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1679893259Medicaid