MEDICARE: KRISTIN ELIZABETH MAPLE PH. D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	3428	OR
2	103G00000X	Clinical Neuropsychologist	3428	OR

General Provider Information

NPI Number	:	1174290415
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTIN ELIZABETH MAPLE PH. D.

Provider Business Mailing Address
First Line	:	837 ALDER CREEK DR
Second Line	:
City	:	MEDFORD
State	:	OR
Zip	:	97504-8900
Country	:	US
Telephone Number	:	541-608-3878
Fax Number	:	541-608-3880

Provider Business Practice Location Address
First Line	:	837 ALDER CREEK DR
Second Line	:
City	:	MEDFORD
State	:	OR
Zip	:	97504-8900
Country	:	US
Telephone Number	:	541-608-3878
Fax Number	:	541-608-3880

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/25/2021
Last Update Date	:	08/25/2021

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