Healthcare Provider Details

I. General information

NPI: 1013180298
Provider Name (Legal Business Name): LIZA R SIMENTAL, PHD HSPP PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/08/2008
Last Update Date: 05/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 E SUNSET LN
WEST LAFAYETTE IN
47906-2456
US

IV. Provider business mailing address

PO BOX 3884
WEST LAFAYETTE IN
47996-3884
US

V. Phone/Fax

Practice location:
  • Phone: 765-532-9084
  • Fax: 765-447-9659
Mailing address:
  • Phone: 765-532-9084
  • Fax: 765-447-9659

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number200251030
License Number StateIN

VIII. Authorized Official

Name: DR. LIZA R RUDOLPH
Title or Position: OWNER
Credential: PH.D.
Phone: 765-532-9084