Provider Demographics
NPI:1245948009
Name:HALL, KELLY NICOLE
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:NICOLE
Last Name:HALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6504 MOUNTAINDALE RD
Mailing Address - Street 2:
Mailing Address - City:THURMONT
Mailing Address - State:MD
Mailing Address - Zip Code:21788-2719
Mailing Address - Country:US
Mailing Address - Phone:443-243-7647
Mailing Address - Fax:
Practice Address - Street 1:6504 MOUNTAINDALE RD
Practice Address - Street 2:
Practice Address - City:THURMONT
Practice Address - State:MD
Practice Address - Zip Code:21788-2719
Practice Address - Country:US
Practice Address - Phone:443-243-7647
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-10
Last Update Date:2023-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDRBT-23-290592103K00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst