Provider Demographics
NPI:1639998107
Name:VAN EMBURGH, KRISTINE MARIE (NCSP)
Entity type:Individual
Prefix:
First Name:KRISTINE
Middle Name:MARIE
Last Name:VAN EMBURGH
Suffix:
Gender:F
Credentials:NCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:726 STANFORD CT
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:MD
Mailing Address - Zip Code:21040-2111
Mailing Address - Country:US
Mailing Address - Phone:732-570-5890
Mailing Address - Fax:
Practice Address - Street 1:910 N EAST RD
Practice Address - Street 2:
Practice Address - City:NORTH EAST
Practice Address - State:MD
Practice Address - Zip Code:21901-1903
Practice Address - Country:US
Practice Address - Phone:410-996-6230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-10
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool