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General NPI Number Information
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NPI Number | 1780259093
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Entity Type | Individual
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Provider Name | KELLY QUEEN
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Gender | Female
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Dates
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Enumeration Date | 05/20/2021
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Last Update Date | 03/27/2023
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Provider Practice Location Address
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Address Line | 1421 CLARKVIEW RD STE 130
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City | BALTIMORE
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State | MD
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Zip | 21209-2184
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Country | US
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Telephone | 844-854-1116
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Fax |
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Provider Business Mailing Address
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Address Line | 9096 REXIS AVE
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City | PERRY HALL
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State | MD
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Zip | 21128-9021
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Country | US
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Telephone | 443-453-2031
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Fax | 443-216-7397
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103K00000X
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Taxonomy Name | Behavior Analyst
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License Number | 1471
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License Number State | MD
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Taxonomy #2
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Taxonomy Code | 106S00000X
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Taxonomy Name | Behavior Technician
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License Number | RBT-19-105390
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License Number State | MD
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Taxonomy #3
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Taxonomy Code | 103K00000X
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Taxonomy Name | Behavior Analyst
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License Number | 1-22-63087
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License Number State | MD
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