Provider Demographics
NPI:1801243589
Name:BURKE, KELLY MARIE (MA, LCPC, CSC-AD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:MARIE
Last Name:BURKE
Suffix:
Gender:F
Credentials:MA, LCPC, CSC-AD
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:MARIE
Other - Last Name:KROSLOWITZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:106 S STRICKER ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21223-2457
Mailing Address - Country:US
Mailing Address - Phone:914-441-3802
Mailing Address - Fax:
Practice Address - Street 1:106 S STRICKER ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21223-2457
Practice Address - Country:US
Practice Address - Phone:914-441-3802
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-23
Last Update Date:2016-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDSC2190101YA0400X
MDLC7089101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)