Provider Demographics
NPI:1689013138
Name:SIMONSON, KEVIN R (PSYD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:R
Last Name:SIMONSON
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FROSTBURG
Mailing Address - State:MD
Mailing Address - Zip Code:21532-1942
Mailing Address - Country:US
Mailing Address - Phone:845-913-6725
Mailing Address - Fax:
Practice Address - Street 1:203 E MAIN ST
Practice Address - Street 2:
Practice Address - City:FROSTBURG
Practice Address - State:MD
Practice Address - Zip Code:21532-1942
Practice Address - Country:US
Practice Address - Phone:845-913-6725
Practice Address - Fax:877-821-5450
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-18
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD05103103TC1900X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD069742701Medicaid