| Doctor Name: | MIA TANYA STULA KELLAM |
| NPI Number: | 1417114240 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | LAC |
| License Number: | 37AC00041700 |
| Business Practice Address: | 339 W 2nd St Bound Brook, NJ - 088051833 |
| Business Phone Number: | 7323561082 |
| Business Fax Number: | 7323566327 |
| Mailing Address: | 339 W 2nd St, BOUND BROOK |
| State: | NJ |
| Postal Code: | 088051833 |
| Phone Number: | 7323561082 |
| Fax Number: | 7323566327 |
| NPI Enumeration Date: | 05/20/2008 |
| NPI Last Update Date: | 05/20/2008 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101YM0800X |
| License Number: | 37AC00041700 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | NJ |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | Mental Health |
| Taxonomy Definition: | |