Provider Demographics
NPI:1306481205
Name:LUMA PSYCHOLOGY PLLC
Entity type:Organization
Organization Name:LUMA PSYCHOLOGY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLAM
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:817-313-7899
Mailing Address - Street 1:2201 DOTTIE LYNN PKWY STE 127
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76120-4435
Mailing Address - Country:US
Mailing Address - Phone:817-313-7899
Mailing Address - Fax:
Practice Address - Street 1:2201 DOTTIE LYNN PKWY STE 127
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76120-4435
Practice Address - Country:US
Practice Address - Phone:817-313-7899
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-14
Last Update Date:2019-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty