Provider Demographics
NPI:1750562013
Name:KELLY, RON ANTON (PSYD)
Entity type:Individual
Prefix:DR
First Name:RON
Middle Name:ANTON
Last Name:KELLY
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10227 DOTTYS WAY
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21044-3886
Mailing Address - Country:US
Mailing Address - Phone:301-233-4658
Mailing Address - Fax:
Practice Address - Street 1:30 GREENWAY ST NW
Practice Address - Street 2:SUITE 5
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-3557
Practice Address - Country:US
Practice Address - Phone:410-760-9079
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-15
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD04369103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical