Provider Demographics
NPI:1578724134
Name:REYNOLDS, KELLY (CAC-AD)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:CAC-AD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 BAY ST STE 307
Mailing Address - Street 2:
Mailing Address - City:EASTON
Mailing Address - State:MD
Mailing Address - Zip Code:21601-2796
Mailing Address - Country:US
Mailing Address - Phone:410-819-5909
Mailing Address - Fax:410-819-0591
Practice Address - Street 1:301 BAY ST STE 307
Practice Address - Street 2:
Practice Address - City:EASTON
Practice Address - State:MD
Practice Address - Zip Code:21601-2796
Practice Address - Country:US
Practice Address - Phone:410-819-5909
Practice Address - Fax:410-819-0591
Is Sole Proprietor?:No
Enumeration Date:2008-06-17
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDAC1464101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)