Healthcare Provider Details

I. General information

NPI: 1083396865
Provider Name (Legal Business Name): LARA SPIEKERMANN PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2023
Last Update Date: 09/29/2023
Certification Date: 09/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 N BROADWAY
BALTIMORE MD
21205-1832
US

IV. Provider business mailing address

1741 ASHLAND AVE
BALTIMORE MD
21205-1531
US

V. Phone/Fax

Practice location:
  • Phone: 443-923-1870
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0810007986
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: