Provider Demographics
NPI:1215534433
Name:KELLY, KATHERINE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:KATHERINE
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1499 CHAIN BRIDGE RD STE 200
Mailing Address - Street 2:
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22101-5704
Mailing Address - Country:US
Mailing Address - Phone:520-560-4018
Mailing Address - Fax:
Practice Address - Street 1:1499 CHAIN BRIDGE RD STE 200
Practice Address - Street 2:
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22101-5704
Practice Address - Country:US
Practice Address - Phone:520-560-4018
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-01
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810007743103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty