Provider Demographics
NPI:1619646916
Name:SAMSON, KRISTAL (PSYD)
Entity Type:Individual
Prefix:DR
First Name:KRISTAL
Middle Name:
Last Name:SAMSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1215 W 10TH ST APT 636
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44113-1281
Mailing Address - Country:US
Mailing Address - Phone:812-243-7157
Mailing Address - Fax:
Practice Address - Street 1:10701 EAST BLVD # 116BW
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106-1702
Practice Address - Country:US
Practice Address - Phone:216-791-3800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-09
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHP.08203103TA0700X, 103TC0700X, 103TH0004X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth