Provider Demographics
NPI:1174290415
Name:MAPLE, KRISTIN ELIZABETH (PH D)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:ELIZABETH
Last Name:MAPLE
Suffix:
Gender:F
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:837 ALDER CREEK DR
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-8900
Mailing Address - Country:US
Mailing Address - Phone:541-608-3878
Mailing Address - Fax:541-608-3880
Practice Address - Street 1:837 ALDER CREEK DR
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-8900
Practice Address - Country:US
Practice Address - Phone:541-608-3878
Practice Address - Fax:541-608-3880
Is Sole Proprietor?:No
Enumeration Date:2021-08-25
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3428103TC0700X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical