Provider Demographics
NPI:1659887735
Name:DELEON KELLAM, MARK ANTHONY
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ANTHONY
Last Name:DELEON KELLAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 LONGMEADOW DR
Mailing Address - Street 2:
Mailing Address - City:HOLBROOK
Mailing Address - State:MA
Mailing Address - Zip Code:02343-2246
Mailing Address - Country:US
Mailing Address - Phone:978-578-6346
Mailing Address - Fax:
Practice Address - Street 1:110 LONGMEADOW DR
Practice Address - Street 2:
Practice Address - City:HOLBROOK
Practice Address - State:MA
Practice Address - Zip Code:02343-2246
Practice Address - Country:US
Practice Address - Phone:978-578-6346
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-27
Last Update Date:2017-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor