Healthcare Provider Details

I. General information

NPI: 1407958325
Provider Name (Legal Business Name): MARK PAUL KELLY PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6900 GEORGIA AVE NW WALTER REED ARMY MEDICAL CENTER
WASHINGTON DC
20307-0003
US

IV. Provider business mailing address

11 STONY MEADOW CT
LUTHERVILLE MD
21093-4532
US

V. Phone/Fax

Practice location:
  • Phone: 202-782-0065
  • Fax: 202-782-7165
Mailing address:
  • Phone: 410-409-8890
  • Fax: 202-752-7165

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number02200
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number02200
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: