Provider Demographics
NPI:1437419280
Name:MORDECAI, KRISTEN (PHD)
Entity Type:Individual
Prefix:DR
First Name:KRISTEN
Middle Name:
Last Name:MORDECAI
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 1:914 VALENCIA CT
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21230-3966
Mailing Address - Country:US
Mailing Address - Phone:773-203-1949
Mailing Address - Fax:
Practice Address - Street 1:10 N GREENE ST
Practice Address - Street 2:VA MARYLAND HEALTHCARE SYSTEM
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1524
Practice Address - Country:US
Practice Address - Phone:410-637-1388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-25
Last Update Date:2012-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD05086103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist