Provider Demographics
NPI:1851052005
Name:KELLAM, ANTHONY JR
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:KELLAM
Suffix:JR
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 1:407 W LITTLE CREEK RD
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23505-2301
Mailing Address - Country:US
Mailing Address - Phone:757-377-6754
Mailing Address - Fax:
Practice Address - Street 1:407 W LITTLE CREEK RD
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23505-2301
Practice Address - Country:US
Practice Address - Phone:757-377-6754
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-09
Last Update Date:2022-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAA60616220405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes405300000XOther Service ProvidersPrevention Professional