Provider Demographics
NPI:1982847364
Name:FOSTER, MARY KRISTIN (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:KRISTIN
Last Name:FOSTER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:K
Other - Last Name:COLEMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:30 E APPLE ST
Mailing Address - Street 2:STE 6254
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45409-2939
Mailing Address - Country:US
Mailing Address - Phone:937-208-2554
Mailing Address - Fax:
Practice Address - Street 1:30 E APPLE ST
Practice Address - Street 2:STE 6254
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45409-2939
Practice Address - Country:US
Practice Address - Phone:937-208-2554
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-14
Last Update Date:2015-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003250103G00000X, 103TC0700X
390200000X
OH7273103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008032500Medicaid
OH0121410Medicaid
OHH439560Medicare PIN
OH0121410Medicaid
CTD400082908 - C00814Medicare PIN