Provider Demographics
NPI:1487267837
Name:KELLERMEYER, KYLE (LGPC)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:KELLERMEYER
Suffix:
Gender:M
Credentials:LGPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1304 ASHBURTON CT
Mailing Address - Street 2:
Mailing Address - City:MILLERSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21108-1900
Mailing Address - Country:US
Mailing Address - Phone:443-883-1309
Mailing Address - Fax:
Practice Address - Street 1:9 NEWBURG AVE STE 200
Practice Address - Street 2:
Practice Address - City:CATONSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21228-5169
Practice Address - Country:US
Practice Address - Phone:410-705-0664
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-26
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD10381101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health