Provider Demographics
NPI:1013180298
Name:LIZA R SIMENTAL, PHD HSPP PC
Entity Type:Organization
Organization Name:LIZA R SIMENTAL, PHD HSPP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LIZA
Authorized Official - Middle Name:R
Authorized Official - Last Name:RUDOLPH
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:765-532-9084
Mailing Address - Street 1:PO BOX 3884
Mailing Address - Street 2:
Mailing Address - City:WEST LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47996-3884
Mailing Address - Country:US
Mailing Address - Phone:765-532-9084
Mailing Address - Fax:765-447-9659
Practice Address - Street 1:255 E SUNSET LN
Practice Address - Street 2:
Practice Address - City:WEST LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47906-2456
Practice Address - Country:US
Practice Address - Phone:765-532-9084
Practice Address - Fax:765-447-9659
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-08
Last Update Date:2016-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN200251030103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN233290Medicare PIN