Provider Demographics
NPI:1114499498
Name:DIBUO, KAY
Entity Type:Individual
Prefix:
First Name:KAY
Middle Name:
Last Name:DIBUO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:617 FRANKLIN AVE
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:MD
Mailing Address - Zip Code:21811-1358
Mailing Address - Country:US
Mailing Address - Phone:410-973-2301
Mailing Address - Fax:410-973-2305
Practice Address - Street 1:35529 JANUS CT
Practice Address - Street 2:
Practice Address - City:FRANKFORD
Practice Address - State:DE
Practice Address - Zip Code:19945-4565
Practice Address - Country:US
Practice Address - Phone:302-212-7091
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-26
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLBA766103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD483106300Medicaid