Provider Demographics
NPI:1285653949
Name:DIEHL, KENNETH W JR (PSYD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:W
Last Name:DIEHL
Suffix:JR
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7518 KNOLLWOOD RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21286-7931
Mailing Address - Country:US
Mailing Address - Phone:410-825-2281
Mailing Address - Fax:410-825-0757
Practice Address - Street 1:1001 CROMWELL BRIDGE RD
Practice Address - Street 2:SUITE 308
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21286-3300
Practice Address - Country:US
Practice Address - Phone:410-337-6760
Practice Address - Fax:410-337-6760
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD01018103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDR15589Medicare UPIN
MDG144Medicare PIN