Healthcare Provider Details

I. General information

NPI: 1689456345
Provider Name (Legal Business Name): MATTHEW KLEIN MA, NCSP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2023
Last Update Date: 10/17/2023
Certification Date: 10/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6009 WESTERN RUN DR
BALTIMORE MD
21209-4007
US

IV. Provider business mailing address

6009 WESTERN RUN DR
BALTIMORE MD
21209-4007
US

V. Phone/Fax

Practice location:
  • Phone: 443-474-4019
  • Fax:
Mailing address:
  • Phone: 443-474-4019
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number16-7458
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: