Provider Demographics
NPI:1114743630
Name:CRESSWELL, KENNETH
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:CRESSWELL
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11720 BELTSVILLE DR STE 500
Mailing Address - Street 2:
Mailing Address - City:BELTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20705-3139
Mailing Address - Country:US
Mailing Address - Phone:410-982-7179
Mailing Address - Fax:
Practice Address - Street 1:11720 BELTSVILLE DR STE 500
Practice Address - Street 2:
Practice Address - City:BELTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20705-3139
Practice Address - Country:US
Practice Address - Phone:410-982-7179
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-30
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR239144363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health