Provider Demographics
NPI:1104866342
Name:PRICE, KELLY ANNE (LCSWC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANNE
Last Name:PRICE
Suffix:
Gender:F
Credentials:LCSWC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 339
Mailing Address - Street 2:
Mailing Address - City:ASHTON
Mailing Address - State:MD
Mailing Address - Zip Code:20861-0339
Mailing Address - Country:US
Mailing Address - Phone:800-491-5369
Mailing Address - Fax:301-774-3678
Practice Address - Street 1:2212 JEFFERSON PIKE
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:MD
Practice Address - Zip Code:21758-9213
Practice Address - Country:US
Practice Address - Phone:800-491-5369
Practice Address - Fax:301-774-3678
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2016-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD132341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD986965400Medicaid
MD214003Medicare ID - Type UnspecifiedFACILITY