Healthcare Provider Details

I. General information

NPI: 1558769661
Provider Name (Legal Business Name): KELLY NICOLE RICHARDSON LCSW-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2014
Last Update Date: 04/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6707 WHITESTONE RD
GWYNN OAK MD
21207-4106
US

IV. Provider business mailing address

6707 WHITESTONE RD
GWYNN OAK MD
21207-4106
US

V. Phone/Fax

Practice location:
  • Phone: 410-265-8737
  • Fax: 410-265-1258
Mailing address:
  • Phone: 410-265-8737
  • Fax: 410-265-1258

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number17243
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number781387
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: