Healthcare Provider Details

I. General information

NPI: 1174290415
Provider Name (Legal Business Name): KRISTIN ELIZABETH MAPLE PH. D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2021
Last Update Date: 08/25/2021
Certification Date: 08/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

837 ALDER CREEK DR
MEDFORD OR
97504-8900
US

IV. Provider business mailing address

837 ALDER CREEK DR
MEDFORD OR
97504-8900
US

V. Phone/Fax

Practice location:
  • Phone: 541-608-3878
  • Fax: 541-608-3880
Mailing address:
  • Phone: 541-608-3878
  • Fax: 541-608-3880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number3428
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number3428
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: