Healthcare Provider Details

I. General information

NPI: 1437996709
Provider Name (Legal Business Name): KAITLIN KENNEFICK LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2024
Last Update Date: 07/12/2024
Certification Date: 07/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5820 YORK RD STE 201
BALTIMORE MD
21212-3620
US

IV. Provider business mailing address

910 SOUTHERLY RD # R351
TOWSON MD
21204-2648
US

V. Phone/Fax

Practice location:
  • Phone: 410-800-2169
  • Fax:
Mailing address:
  • Phone: 508-857-6793
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number31839
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: