Provider Demographics
NPI:1952488199
Name:KELLEY, ANTOINETTE MARY (LCPC)
Entity Type:Individual
Prefix:MRS
First Name:ANTOINETTE
Middle Name:MARY
Last Name:KELLEY
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:TONI
Other - Middle Name:
Other - Last Name:KELLEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCPC
Mailing Address - Street 1:1620 ELTON RD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20903-1740
Mailing Address - Country:US
Mailing Address - Phone:301-439-7191
Mailing Address - Fax:
Practice Address - Street 1:12607 CLARK MEADOWS CT
Practice Address - Street 2:
Practice Address - City:CLARKSBURG
Practice Address - State:MD
Practice Address - Zip Code:20871-4000
Practice Address - Country:US
Practice Address - Phone:240-498-1648
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC2067101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD7539782OtherAETNA
DCF127-0028OtherBLUE CROSS BLUE SHIELD
MDLV12/647371-01OtherBLUE CROSS BLUE SHIELD
MD2143850OtherMAMSI