Provider Demographics
NPI:1730309501
Name:ACKERMAN, KATHLEEN CANTWELL (MD)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:CANTWELL
Last Name:ACKERMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 E DIAMOND AVE
Mailing Address - Street 2:100A
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20877-5321
Mailing Address - Country:US
Mailing Address - Phone:301-840-3200
Mailing Address - Fax:301-840-1348
Practice Address - Street 1:610 E DIAMOND AVE
Practice Address - Street 2:100A
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20877-5321
Practice Address - Country:US
Practice Address - Phone:301-840-3200
Practice Address - Fax:301-840-1348
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2012-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00275552084P0015X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0015XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychosomatic Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD816700100Medicaid