Provider Demographics
NPI:1588315964
Name:GEBHARD, KRISTOPHER T
Entity type:Individual
Prefix:
First Name:KRISTOPHER
Middle Name:T
Last Name:GEBHARD
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:PO BOX 33458
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21218-0408
Mailing Address - Country:US
Mailing Address - Phone:218-280-2750
Mailing Address - Fax:
Practice Address - Street 1:3600 ROLAND AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21211-2437
Practice Address - Country:US
Practice Address - Phone:443-320-2313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-17
Last Update Date:2024-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD06996103TC0700X
IL071.010702103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical