Provider Demographics
NPI:1821796814
Name:MCKELLAR, JAMES AUSTIN
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:AUSTIN
Last Name:MCKELLAR
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 1:5931 SEQUOIA LN
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135-5577
Mailing Address - Country:US
Mailing Address - Phone:607-205-4841
Mailing Address - Fax:
Practice Address - Street 1:667 FAIRBURN RD NW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30331-1423
Practice Address - Country:US
Practice Address - Phone:404-586-9595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-20
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-22-233371106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician