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General NPI Number Information
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NPI Number | 1790233666
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Entity Type | Organization
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Legal Business Name | KENNETH M. KLEBANOW, M.D. & ASSOCIATES, P.A.
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Dates
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Enumeration Date | 09/20/2016
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Last Update Date | 07/28/2022
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Provider Practice Location Address
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Address Line | 8821 COLUMBIA 100 PKWY
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City | COLUMBIA
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State | MD
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Zip | 21045
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Country | US
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Telephone | 410-997-1700
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Fax | 410-740-8315
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Provider Business Mailing Address
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Address Line | 8821 COLUMBIA 100 PKWY
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City | COLUMBIA
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State | MD
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Zip | 21045
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Country | US
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Telephone | 410-997-1700
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Fax | 410-740-8315
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Authorized Official
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Title or Position | PSYCHOLOGIST
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Name | JESSICA K. WINKLES
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Credential | PHD
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Telephone | 410-794-4924
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC2200X
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Taxonomy Name | Clinical Child & Adolescent Psychologist
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License Number | 05562
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License Number State | MD
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