Provider Demographics
NPI:1982275616
Name:KELLEY, KATHERINE
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:KELLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:218 TIMBER VIEW CT
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21702-5508
Mailing Address - Country:US
Mailing Address - Phone:301-524-4255
Mailing Address - Fax:
Practice Address - Street 1:324 S JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21701-6286
Practice Address - Country:US
Practice Address - Phone:301-882-7932
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-04
Last Update Date:2021-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician