Healthcare Provider Details

I. General information

NPI: 1588315964
Provider Name (Legal Business Name): KRISTOPHER T GEBHARD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/17/2022
Last Update Date: 05/03/2024
Certification Date: 05/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 ROLAND AVE
BALTIMORE MD
21211-2437
US

IV. Provider business mailing address

PO BOX 33458
BALTIMORE MD
21218-0408
US

V. Phone/Fax

Practice location:
  • Phone: 443-320-2313
  • Fax:
Mailing address:
  • Phone: 218-280-2750
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number06996
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071.010702
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: