Provider Demographics
NPI:1972686202
Name:KELLAM, VICKI LEIGH (LICSW)
Entity type:Individual
Prefix:MRS
First Name:VICKI
Middle Name:LEIGH
Last Name:KELLAM
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:281 WINTER ST STE 340
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02451-8766
Mailing Address - Country:US
Mailing Address - Phone:781-317-6009
Mailing Address - Fax:
Practice Address - Street 1:281 WINTER ST STE 340
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02451-8766
Practice Address - Country:US
Practice Address - Phone:617-999-2184
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2025-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1152641041C0700X
104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1303287OtherMBHP
042611055OtherTAX ID
MA1303287Medicaid
703136OtherTUFTS
MA1004745OtherNHP
996OtherNETWORK HEALTH
M18633OtherBCBS
NP01332OtherBOSTON MED