1578691895 NPI number — VALERIE L KELLOM M.S.S.

Table of content: VALERIE L KELLOM M.S.S. (NPI 1578691895)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578691895 NPI number — VALERIE L KELLOM M.S.S.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KELLOM
Provider First Name:
VALERIE
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.S.S.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1578691895
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
807 W MOUNT VERNON AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HADDONFIELD
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08033-3034
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
856-429-7690
Provider Business Mailing Address Fax Number:
215-790-1771

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
315 S 22ND ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19103-2559
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-790-1770
Provider Business Practice Location Address Fax Number:
215-790-1771
Provider Enumeration Date:
02/28/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  SC-00847500 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: CW-012860 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: SC-00847500 . This is a "LCSW" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 022505 . This is a "BCD" identifier . This identifiers is of the category "OTHER".
  • Identifier: CW-012860 . This is a "LCSW" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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