Provider Demographics
NPI:1124720222
Name:COULTHARD, KELSEY GNADE (PHD)
Entity type:Individual
Prefix:DR
First Name:KELSEY
Middle Name:GNADE
Last Name:COULTHARD
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:951 FELL ST APT 406
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21231-3591
Mailing Address - Country:US
Mailing Address - Phone:843-437-6673
Mailing Address - Fax:
Practice Address - Street 1:1750 E FAIRMOUNT AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21231-1534
Practice Address - Country:US
Practice Address - Phone:443-923-4328
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-21
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD07226103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent