MEDICARE: LIZA R SIMENTAL, PHD HSPP PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	200251030	IN

General Provider Information

NPI Number	:	1013180298
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIZA R SIMENTAL, PHD HSPP PC

Provider Business Mailing Address
First Line	:	PO BOX 3884
Second Line	:
City	:	WEST LAFAYETTE
State	:	IN
Zip	:	47996-3884
Country	:	US
Telephone Number	:	765-532-9084
Fax Number	:	765-447-9659

Provider Business Practice Location Address
First Line	:	255 E SUNSET LN
Second Line	:
City	:	WEST LAFAYETTE
State	:	IN
Zip	:	47906-2456
Country	:	US
Telephone Number	:	765-532-9084
Fax Number	:	765-447-9659

Authorized Official
Title or Position	:	OWNER
Name	:	DR. LIZA R RUDOLPH
Credential	:	PH.D.
Telephone Number	:	765-532-9084

Provider Enumeration Date	:	04/08/2008
Last Update Date	:	05/05/2016

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