Provider Demographics
NPI:1801383781
Name:KELSEY, SHANE (LGPC)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:KELSEY
Suffix:
Gender:M
Credentials:LGPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5022 CAMPBELL BLVD STE L
Mailing Address - Street 2:
Mailing Address - City:NOTTINGHAM
Mailing Address - State:MD
Mailing Address - Zip Code:21236-4969
Mailing Address - Country:US
Mailing Address - Phone:443-442-1568
Mailing Address - Fax:443-442-1569
Practice Address - Street 1:5022 CAMPBELL BLVD STE L
Practice Address - Street 2:
Practice Address - City:NOTTINGHAM
Practice Address - State:MD
Practice Address - Zip Code:21236-4969
Practice Address - Country:US
Practice Address - Phone:443-442-1568
Practice Address - Fax:443-442-1569
Is Sole Proprietor?:No
Enumeration Date:2018-04-17
Last Update Date:2018-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP8575101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor