Provider Demographics
NPI:1407958325
Name:KELLY, MARK PAUL (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:PAUL
Last Name:KELLY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
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Mailing Address - Street 1:11 STONY MEADOW CT
Mailing Address - Street 2:
Mailing Address - City:LUTHERVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21093-4532
Mailing Address - Country:US
Mailing Address - Phone:410-409-8890
Mailing Address - Fax:202-752-7165
Practice Address - Street 1:6900 GEORGIA AVE NW
Practice Address - Street 2:WALTER REED ARMY MEDICAL CENTER
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20307-0003
Practice Address - Country:US
Practice Address - Phone:202-782-0065
Practice Address - Fax:202-782-7165
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MD02200103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical