Provider Demographics
NPI:1750674511
Name:ANDERSON, KRISTIN NOEL (PHD)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:NOEL
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10269 SMUGGLERS CV
Mailing Address - Street 2:
Mailing Address - City:REMINDERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44202-9047
Mailing Address - Country:US
Mailing Address - Phone:419-340-5457
Mailing Address - Fax:
Practice Address - Street 1:190 CURRIE HALL PKWY
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:OH
Practice Address - Zip Code:44240-4312
Practice Address - Country:US
Practice Address - Phone:330-673-5812
Practice Address - Fax:330-673-7162
Is Sole Proprietor?:No
Enumeration Date:2011-05-25
Last Update Date:2020-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH7503103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0201447Medicaid