Provider Demographics
NPI:1194442558
Name:MUTHEE, KENNETH G
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:G
Last Name:MUTHEE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 SIPPLE AVE
Mailing Address - Street 2:
Mailing Address - City:NOTTINGHAM
Mailing Address - State:MD
Mailing Address - Zip Code:21236-4226
Mailing Address - Country:US
Mailing Address - Phone:443-635-5572
Mailing Address - Fax:
Practice Address - Street 1:1340 SMITH AVE STE 200
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21209-3796
Practice Address - Country:US
Practice Address - Phone:443-500-9251
Practice Address - Fax:410-779-1314
Is Sole Proprietor?:No
Enumeration Date:2022-10-25
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR221983364SP0812X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No364SP0812XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Community