Basic Information
Provider Information | |||||||||
NPI: | 1639571375 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WAN | ||||||||
FirstName: | KAYAN | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PSYD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | WAN | ||||||||
OtherFirstName: | KAYAN | ||||||||
OtherMiddleName: | PHOEBE | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PSY.D. | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 6501 N CHARLES ST # D228 | ||||||||
Address2: |   | ||||||||
City: | BALTIMORE | ||||||||
State: | MD | ||||||||
PostalCode: | 212046819 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4109383461 | ||||||||
FaxNumber: | 4109384361 | ||||||||
Practice Location | |||||||||
Address1: | 6501 N CHARLES ST # D228 | ||||||||
Address2: |   | ||||||||
City: | BALTIMORE | ||||||||
State: | MD | ||||||||
PostalCode: | 212046819 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4109383461 | ||||||||
FaxNumber: | 4109384361 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/25/2014 | ||||||||
LastUpdateDate: | 06/16/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/16/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 2014031994 | MO | N |   | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC0700X | 06388 | MD | Y |   | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.