=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538629969
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | INGRID KIEHL
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/21/2019
-----------------------------------------------------
Last Update Date | 07/23/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 396 WASHINGTON ST # 266
-----------------------------------------------------
City | WELLESLEY HILLS
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02481-6209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 855-438-8331
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 670 PALACIA CT
-----------------------------------------------------
City | TURLOCK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95380-4432
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-605-0518
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0804X
-----------------------------------------------------
Taxonomy Name | Child & Adolescent Psychiatry Physician
-----------------------------------------------------
License Number | 292785
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------