Provider Demographics
NPI:1235807512
Name:KYDES, STEFANIE ALISON MOYNIHAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:STEFANIE
Middle Name:ALISON MOYNIHAN
Last Name:KYDES
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:STEFANIE
Other - Middle Name:ALISON
Other - Last Name:MOYNIHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:220 BOWEN CT
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-1945
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:220 BOWEN CT
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-1945
Practice Address - Country:US
Practice Address - Phone:617-943-9640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-01
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD07009103TC0700X
KSLP03048103TC0700X
WAPY61149309103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
11870OtherASPPB E.PASSPORT/APIT MOBILITY NUMBER
FLTPPY1243OtherOUT-OF-STATE TELEHEALTH PROVIDER REGISTRATION