Deidra Kelly, CAC

Primary specialty

Addiction (Substance Use Disorder) CounselorTaxonomy code 101YA0400X

License

AC2833 Issued in MD

Practice address

112 E Patapsco Ave
Brooklyn, MD 21225-1745

Phone

(667) 260-2595

NPI assigned

Jun 14, 2021

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1623628800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1623628800000",
    "number": "1770151136",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "723 STAFFORD HILL DR",
            "city": "GLEN BURNIE",
            "state": "MD",
            "postal_code": "210614879",
            "telephone_number": "410-967-9131"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "112 E PATAPSCO AVE",
            "city": "BROOKLYN",
            "state": "MD",
            "postal_code": "212251745",
            "telephone_number": "667-260-2595"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "4268 Sands Rd",
            "address_purpose": "LOCATION",
            "city": "Harwood",
            "state": "MD",
            "postal_code": "207769419",
            "country_code": "US",
            "telephone_number": "410-967-9131",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "KELLY",
        "first_name": "DEIDRA",
        "name_prefix": "Ms.",
        "credential": "CAC",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2021-06-14",
        "last_updated": "2021-06-14",
        "certification_date": "2021-06-14",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "101YA0400X",
            "taxonomy_group": "",
            "desc": "Counselor, Addiction (Substance Use Disorder)",
            "state": "MD",
            "license": "AC2833",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Addiction (Substance Use Disorder) Counselor in Brooklyn, MD
• Providers in Brooklyn, MD by specialty
• Addiction (Substance Use Disorder) Counselor in Maryland

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 14, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.