Healthcare Provider Details

I. General information

NPI: 1336647551
Provider Name (Legal Business Name): DUSTIN SENTZ LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2018
Last Update Date: 07/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1107 KENILWORTH DR STE 208
TOWSON MD
21204
US

IV. Provider business mailing address

1107 KENILWORTH DR STE 208
TOWSON MD
21204-2136
US

V. Phone/Fax

Practice location:
  • Phone: 410-370-0299
  • Fax:
Mailing address:
  • Phone: 410-370-0299
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number04247
License Number StateMD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. DUSTIN FORRESTER SENTZ
Title or Position: PRESIDENT
Credential: PSY D
Phone: 410-370-0299