Provider Demographics
NPI:1124106000
Name:FENZEL, LEO F JR (PHD)
Entity type:Individual
Prefix:DR
First Name:LEO
Middle Name:F
Last Name:FENZEL
Suffix:JR
Gender:M
Credentials:PHD
Other - Prefix:DR
Other - First Name:MICKEY
Other - Middle Name:
Other - Last Name:FENZEL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:28 ALLEGHENY AVE
Mailing Address - Street 2:SUITE 1208
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21204-3909
Mailing Address - Country:US
Mailing Address - Phone:410-617-2640
Mailing Address - Fax:410-617-5097
Practice Address - Street 1:28 ALLEGHENY AVE
Practice Address - Street 2:SUITE 1208
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-3909
Practice Address - Country:US
Practice Address - Phone:410-617-2640
Practice Address - Fax:410-617-5097
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD02810103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD02810OtherPSYCHOLOGIST LICENSE