Provider Demographics
NPI:1174523377
Name:KELLY, SAMUEL JAMES III (LCSW-C)
Entity type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:JAMES
Last Name:KELLY
Suffix:III
Gender:M
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:3316 BATAVIA AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21214-2609
Mailing Address - Country:US
Mailing Address - Phone:410-444-7621
Mailing Address - Fax:
Practice Address - Street 1:200 E JOPPA RD
Practice Address - Street 2:SUITE 108
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21286-3150
Practice Address - Country:US
Practice Address - Phone:410-583-8846
Practice Address - Fax:410-583-9297
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD078741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD842RMedicare ID - Type Unspecified