Healthcare Provider Details

I. General information

NPI: 1922698398
Provider Name (Legal Business Name): EARL THOMAS KELLEY JR. LCSW-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2021
Last Update Date: 10/27/2023
Certification Date: 10/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 W SARATOGA ST
BALTIMORE MD
21223-1749
US

IV. Provider business mailing address

1501 W SARATOGA ST
BALTIMORE MD
21223-1749
US

V. Phone/Fax

Practice location:
  • Phone: 410-383-8300
  • Fax: 410-735-5264
Mailing address:
  • Phone: 410-383-8300
  • Fax: 410-735-5264

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number26501
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: