Provider Demographics
NPI:1184740185
Name:KIEDERER, KELLY A (LCPC)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:A
Last Name:KIEDERER
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:MRS
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:KIEDERER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCPC
Mailing Address - Street 1:26 POPLAR SPRINGS BLVD
Mailing Address - Street 2:
Mailing Address - City:STEWARTSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:17363-4105
Mailing Address - Country:US
Mailing Address - Phone:443-928-0631
Mailing Address - Fax:
Practice Address - Street 1:900 S MAIN ST BLDG A
Practice Address - Street 2:SUITE 105
Practice Address - City:BEL AIR
Practice Address - State:MD
Practice Address - Zip Code:21014-5447
Practice Address - Country:US
Practice Address - Phone:410-914-4012
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2024-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
MDLC2184101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDM3280013OtherBCBS NATL CAPITAL REGION
MDQC40COOtherCAREFIRST BCBS MD
MDAETNAOther7265936
MD600007820OtherMAGELLAN BH
MD88750701OtherCAREFIRST RENDERING