Provider Demographics
NPI:1235774696
Name:KELLEY, MARY KATHLEEN D (RN, LPC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KATHLEEN D
Last Name:KELLEY
Suffix:
Gender:F
Credentials:RN, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 BESTGATE RD STE 325
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-4291
Mailing Address - Country:US
Mailing Address - Phone:703-831-8300
Mailing Address - Fax:
Practice Address - Street 1:810 BESTGATE RD STE 325
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-3648
Practice Address - Country:US
Practice Address - Phone:571-344-4224
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-08
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701010214101YM0800X
VA0001152431163W00000X
MDLC13328101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No163W00000XNursing Service ProvidersRegistered Nurse