Provider Demographics
NPI:1689248544
Name:KELLAR, TOMMY LEWIS
Entity Type:Individual
Prefix:
First Name:TOMMY
Middle Name:LEWIS
Last Name:KELLAR
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 1:3871 SUNCREST RD
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33467-1541
Mailing Address - Country:US
Mailing Address - Phone:585-432-4193
Mailing Address - Fax:
Practice Address - Street 1:3871 SUNCREST RD
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33467-1541
Practice Address - Country:US
Practice Address - Phone:585-432-4193
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-16
Last Update Date:2021-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLK460812711650101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health