Provider Demographics
NPI:1891189825
Name:KELLAM, MARY HELEN
Entity Type:Individual
Prefix:
First Name:MARY HELEN
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 1:17 WOODPORT RD
Mailing Address - Street 2:SUITE 2D
Mailing Address - City:SPARTA
Mailing Address - State:NJ
Mailing Address - Zip Code:07871-2412
Mailing Address - Country:US
Mailing Address - Phone:201-317-4539
Mailing Address - Fax:
Practice Address - Street 1:17 WOODPORT RD
Practice Address - Street 2:SUITE 2D
Practice Address - City:SPARTA
Practice Address - State:NJ
Practice Address - Zip Code:07871-2412
Practice Address - Country:US
Practice Address - Phone:201-317-4539
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-27
Last Update Date:2015-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00514800101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional