Provider Demographics
NPI:1821634718
Name:KELLAM, MARIA
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:KELLAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4412 17TH ST S
Mailing Address - Street 2:
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56560-7143
Mailing Address - Country:US
Mailing Address - Phone:701-320-1514
Mailing Address - Fax:
Practice Address - Street 1:2800 MAIN AVE
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-6811
Practice Address - Country:US
Practice Address - Phone:701-365-8868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-26
Last Update Date:2019-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician