Provider Demographics
NPI:1659007540
Name:KELLY, RICHARD LEE JR
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:LEE
Last Name:KELLY
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3218 NORMOUNT AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21216-3821
Mailing Address - Country:US
Mailing Address - Phone:443-414-6873
Mailing Address - Fax:
Practice Address - Street 1:3218 NORMOUNT AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21216-3821
Practice Address - Country:US
Practice Address - Phone:443-414-6873
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-25
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)