Provider Demographics
NPI:1578691895
Name:KELLOM, VALERIE L (MSS)
Entity Type:Individual
Prefix:
First Name:VALERIE
Middle Name:L
Last Name:KELLOM
Suffix:
Gender:F
Credentials:MSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:807 W MOUNT VERNON AVE
Mailing Address - Street 2:
Mailing Address - City:HADDONFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:08033-3034
Mailing Address - Country:US
Mailing Address - Phone:856-429-7690
Mailing Address - Fax:215-790-1771
Practice Address - Street 1:315 S 22ND ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19103-2559
Practice Address - Country:US
Practice Address - Phone:215-790-1770
Practice Address - Fax:215-790-1771
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJSC-008475001041C0700X
PACW-0128601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJSC-00847500OtherLCSW
022505OtherBCD
PACW-012860OtherLCSW