Provider Demographics
NPI:1679368120
Name:WALSH, KELLY (MA, CAS, NCSP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:WALSH
Suffix:
Gender:
Credentials:MA, CAS, NCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7728 FONTAINE ST
Mailing Address - Street 2:
Mailing Address - City:POTOMAC
Mailing Address - State:MD
Mailing Address - Zip Code:20854-3303
Mailing Address - Country:US
Mailing Address - Phone:240-997-9646
Mailing Address - Fax:
Practice Address - Street 1:7728 FONTAINE ST
Practice Address - Street 2:
Practice Address - City:POTOMAC
Practice Address - State:MD
Practice Address - Zip Code:20854-3303
Practice Address - Country:US
Practice Address - Phone:240-997-9646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-14
Last Update Date:2025-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD1001799609103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool