Provider Demographics
NPI:1043573454
Name:DAVIDSON, KRISTEN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:KRISTEN
Middle Name:
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:KRISTEN
Other - Middle Name:
Other - Last Name:DOMBOSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2497 WAVING MOSS WAY
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32792-3041
Mailing Address - Country:US
Mailing Address - Phone:407-793-1282
Mailing Address - Fax:833-895-1282
Practice Address - Street 1:2497 WAVING MOSS WAY
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792-3041
Practice Address - Country:US
Practice Address - Phone:407-793-1282
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-20
Last Update Date:2023-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY11597103G00000X
OK1152103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200435510AMedicaid