Provider Demographics
NPI:1740396456
Name:KINNEY, JUDITH M (PHD)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:M
Last Name:KINNEY
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 1:20 CROSSROADS DR STE 104
Mailing Address - Street 2:
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-5480
Mailing Address - Country:US
Mailing Address - Phone:410-371-5092
Mailing Address - Fax:
Practice Address - Street 1:20 CROSSROADS DR STE 104
Practice Address - Street 2:
Practice Address - City:OWINGS MILLS
Practice Address - State:MD
Practice Address - Zip Code:21117-5480
Practice Address - Country:US
Practice Address - Phone:410-371-5092
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-23
Last Update Date:2017-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD03359103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD254810100Medicaid