Provider Demographics
NPI:1114167087
Name:TARQUIN, KRISTEN M (PHD)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:M
Last Name:TARQUIN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:808 ESTUARY DR
Mailing Address - Street 2:
Mailing Address - City:ODENTON
Mailing Address - State:MD
Mailing Address - Zip Code:21113-4017
Mailing Address - Country:US
Mailing Address - Phone:443-584-3532
Mailing Address - Fax:
Practice Address - Street 1:1190 WINTERSON RD
Practice Address - Street 2:SUITE 160
Practice Address - City:LINTHICUM
Practice Address - State:MD
Practice Address - Zip Code:21090-2209
Practice Address - Country:US
Practice Address - Phone:443-584-3532
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-04
Last Update Date:2015-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD04469103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical