Provider Demographics
NPI:1760547954
Name:KELLAM, ALFRED GEORGE (PHD)
Entity Type:Individual
Prefix:
First Name:ALFRED
Middle Name:GEORGE
Last Name:KELLAM
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 E WASHINGTON ST
Mailing Address - Street 2:SUITE 510
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48104-2017
Mailing Address - Country:US
Mailing Address - Phone:734-996-1944
Mailing Address - Fax:
Practice Address - Street 1:202 E WASHINGTON ST
Practice Address - Street 2:SUITE 510
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-2017
Practice Address - Country:US
Practice Address - Phone:734-996-1944
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-27
Last Update Date:2012-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301006080103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6301006080OtherLICENSE