Healthcare Provider Details

I. General information

NPI: 1346240173
Provider Name (Legal Business Name): DR. KENNETH TERCYAK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 RESERVOIR RD NW
WASHINGTON DC
20007-2145
US

IV. Provider business mailing address

4000 RESERVOIR RD NW
WASHINGTON DC
20007-2145
US

V. Phone/Fax

Practice location:
  • Phone: 202-444-2224
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number3702
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY1000152
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: