Healthcare Provider Details

I. General information

NPI: 1154081859
Provider Name (Legal Business Name): SUSAN KELLY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/21/2021
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7140 WINTER ROSE PATH
COLUMBIA MD
21045-5132
US

IV. Provider business mailing address

7140 WINTER ROSE PATH
COLUMBIA MD
21045-5132
US

V. Phone/Fax

Practice location:
  • Phone: 401-537-8877
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34661
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCW025422
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number128353
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: