Provider Demographics
NPI:1366230732
Name:KELLUM, RENDEL
Entity type:Individual
Prefix:
First Name:RENDEL
Middle Name:
Last Name:KELLUM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 W 132ND ST APT 3U
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10037-3106
Mailing Address - Country:US
Mailing Address - Phone:910-388-7644
Mailing Address - Fax:
Practice Address - Street 1:527 COURT ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11231-4450
Practice Address - Country:US
Practice Address - Phone:917-444-5855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-28
Last Update Date:2025-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health