Provider Demographics
NPI:1487262838
Name:KALISH, JENNIFER LANUZGA (PSYD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LANUZGA
Last Name:KALISH
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7820B WORMANS MILL RD
Mailing Address - Street 2:BX 239
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21701
Mailing Address - Country:US
Mailing Address - Phone:301-450-1273
Mailing Address - Fax:
Practice Address - Street 1:7007 BRADLEY BLVD
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20817-2149
Practice Address - Country:US
Practice Address - Phone:301-767-1733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-21
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD06937103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD06937OtherPSYCHOLOGIST LICENSE