Provider Demographics
NPI:1265640692
Name:KELLY, MAURINE KELBER (PHD)
Entity Type:Individual
Prefix:DR
First Name:MAURINE
Middle Name:KELBER
Last Name:KELLY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11621 YEATMAN TERRACE
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20902-3057
Mailing Address - Country:US
Mailing Address - Phone:301-649-1896
Mailing Address - Fax:301-649-1843
Practice Address - Street 1:4809 ST ELMO AVENUE
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20814-3009
Practice Address - Country:US
Practice Address - Phone:301-649-1896
Practice Address - Fax:301-649-1843
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD1331103T00000X
DC1507103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
699072Medicare ID - Type Unspecified