Provider Demographics
NPI:1144349408
Name:BENTON-KLEIN, KELLY SAMANTHA (PSYD)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:SAMANTHA
Last Name:BENTON-KLEIN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:KELLY
Other - Middle Name:SAMANTHA
Other - Last Name:KLEIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PSYD
Mailing Address - Street 1:8602 BOVELDER DR
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20708-3519
Mailing Address - Country:US
Mailing Address - Phone:240-264-6387
Mailing Address - Fax:301-474-1828
Practice Address - Street 1:7225 HANOVER PKWY
Practice Address - Street 2:BLDG. 7 A-B
Practice Address - City:GREENBELT
Practice Address - State:MD
Practice Address - Zip Code:20770-2024
Practice Address - Country:US
Practice Address - Phone:301-585-2977
Practice Address - Fax:301-474-1828
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD04240103TC0700X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD315758OtherAMERIGROUP