Provider Demographics
NPI:1265023493
Name:ROGAN, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:ROGAN
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 1:101 W RIDGELY RD STE 8A
Mailing Address - Street 2:
Mailing Address - City:LUTHERVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21093-5124
Mailing Address - Country:US
Mailing Address - Phone:410-870-4655
Mailing Address - Fax:
Practice Address - Street 1:101 W RIDGELY RD STE 8A
Practice Address - Street 2:
Practice Address - City:LUTHERVILLE
Practice Address - State:MD
Practice Address - Zip Code:21093-5124
Practice Address - Country:US
Practice Address - Phone:410-870-4655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-31
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP10484101YM0800X
MDLC14577101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health