Healthcare Provider Details

I. General information

NPI: 1689013138
Provider Name (Legal Business Name): KEVIN R SIMONSON PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2013
Last Update Date: 12/01/2021
Certification Date: 12/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 E MAIN ST
FROSTBURG MD
21532-1942
US

IV. Provider business mailing address

203 E MAIN ST
FROSTBURG MD
21532-1942
US

V. Phone/Fax

Practice location:
  • Phone: 845-913-6725
  • Fax: 877-821-5450
Mailing address:
  • Phone: 845-913-6725
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number05103
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number05103
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: