Healthcare Provider Details

I. General information

NPI: 1285653949
Provider Name (Legal Business Name): KENNETH W DIEHL JR. PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 03/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 CROMWELL BRIDGE RD SUITE 308
BALTIMORE MD
21286-3300
US

IV. Provider business mailing address

7518 KNOLLWOOD RD
BALTIMORE MD
21286-7931
US

V. Phone/Fax

Practice location:
  • Phone: 410-337-6760
  • Fax: 410-337-6760
Mailing address:
  • Phone: 410-825-2281
  • Fax: 410-825-0757

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number01018
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: