Provider Demographics
NPI:1871214510
Name:KELLYS SUPPORT SERVICES OF MARYLAND
Entity type:Organization
Organization Name:KELLYS SUPPORT SERVICES OF MARYLAND
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DURECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:ANYE
Authorized Official - Last Name:MIYANG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-444-1550
Mailing Address - Street 1:3920 ROCK SPRING DR
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20772-3993
Mailing Address - Country:US
Mailing Address - Phone:919-444-1550
Mailing Address - Fax:
Practice Address - Street 1:3920 ROCK SPRING DR
Practice Address - Street 2:
Practice Address - City:UPPER MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20772-3993
Practice Address - Country:US
Practice Address - Phone:919-444-1550
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-12
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities