Provider Demographics
NPI:1952662520
Name:KLASTAVA, KELLY BEAUDRY (LCSW-C)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:BEAUDRY
Last Name:KLASTAVA
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 ARLEN RD
Mailing Address - Street 2:APARTMENT I
Mailing Address - City:NOTTINGHAM
Mailing Address - State:MD
Mailing Address - Zip Code:21236-5165
Mailing Address - Country:US
Mailing Address - Phone:732-456-0829
Mailing Address - Fax:
Practice Address - Street 1:135 N PARKE ST
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:MD
Practice Address - Zip Code:21001-2428
Practice Address - Country:US
Practice Address - Phone:443-625-1600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-31
Last Update Date:2013-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD16610251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health