Provider Demographics
NPI:1447431994
Name:KELLAM, DAMIEN DIABLO (MA, LPC, PHD ABD)
Entity type:Individual
Prefix:
First Name:DAMIEN
Middle Name:DIABLO
Last Name:KELLAM
Suffix:
Gender:M
Credentials:MA, LPC, PHD ABD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1871
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-8871
Mailing Address - Country:US
Mailing Address - Phone:404-337-0305
Mailing Address - Fax:
Practice Address - Street 1:2220 LAKE HARBIN RD
Practice Address - Street 2:
Practice Address - City:MORROW
Practice Address - State:GA
Practice Address - Zip Code:30260-1907
Practice Address - Country:US
Practice Address - Phone:404-337-0305
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-26
Last Update Date:2013-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA101YM0800X
101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health