Basic Information
| Provider Information | |||||||||
| NPI: | 1538634423 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KELEM | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | B. | ||||||||
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| Credential: | LMFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 670 9TH ST STE 203 | ||||||||
| Address2: | |||||||||
| City: | ARCATA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955216249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7078268633 | ||||||||
| FaxNumber: | 7078268638 | ||||||||
| Practice Location | |||||||||
| Address1: | 550 E WASHINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | CRESCENT CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955318160 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074656925 | ||||||||
| FaxNumber: | 7074656070 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/08/2018 | ||||||||
| LastUpdateDate: | 10/08/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 030406 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.