Provider Demographics
NPI:1841467685
Name:KNODE, KELLY LYNN (CSC-AD)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:LYNN
Last Name:KNODE
Suffix:
Gender:F
Credentials:CSC-AD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13114 PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21742-2741
Mailing Address - Country:US
Mailing Address - Phone:240-313-3254
Mailing Address - Fax:240-313-3239
Practice Address - Street 1:13114 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21742-2741
Practice Address - Country:US
Practice Address - Phone:240-313-3254
Practice Address - Fax:240-313-3239
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-12
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDSC0630101YA0400X
MDSC060101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)