Healthcare Provider Details

I. General information

NPI: 1619646916
Provider Name (Legal Business Name): KRISTAL SAMSON PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2021
Last Update Date: 09/09/2021
Certification Date: 09/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10701 EAST BLVD # 116BW
CLEVELAND OH
44106-1702
US

IV. Provider business mailing address

1215 W 10TH ST APT 636
CLEVELAND OH
44113-1281
US

V. Phone/Fax

Practice location:
  • Phone: 216-791-3800
  • Fax:
Mailing address:
  • Phone: 812-243-7157
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License NumberP.08203
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberP.08203
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License NumberP.08203
License Number StateOH
# 4
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberP.08203
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: