Healthcare Provider Details

I. General information

NPI: 1730409079
Provider Name (Legal Business Name): KRISTEN ELIZABETH SMITH-SIMON PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2010
Last Update Date: 05/19/2021
Certification Date: 04/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

454 ROLLING RIDGE DR
STATE COLLEGE PA
16801-7696
US

IV. Provider business mailing address

337 MOORE BUILDING
UNIVERSITY PARK PA
16802
US

V. Phone/Fax

Practice location:
  • Phone: 814-235-1100
  • Fax: 814-235-1101
Mailing address:
  • Phone: 814-865-2191
  • Fax: 814-863-1331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPS016744
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: