Provider Demographics
NPI:1407079171
Name:WETZEL, KELLY D (LCPC)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:D
Last Name:WETZEL
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 LANGLEY ROAD NORTH
Mailing Address - Street 2:SUITE B
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21060
Mailing Address - Country:US
Mailing Address - Phone:410-222-0100
Mailing Address - Fax:410-222-0116
Practice Address - Street 1:122 LANGLEY ROAD NORTH
Practice Address - Street 2:SUITE B
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21060
Practice Address - Country:US
Practice Address - Phone:410-222-0100
Practice Address - Fax:410-222-0116
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC1022101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)