Provider Demographics
NPI:1528143153
Name:SAMUELSON, KRISTIN WEAVER (PHD)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:WEAVER
Last Name:SAMUELSON
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 1:410 BRANDYWINE DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906-4847
Mailing Address - Country:US
Mailing Address - Phone:415-713-9841
Mailing Address - Fax:
Practice Address - Street 1:VETERANS HEALTH AND TRAUMA CLINIC
Practice Address - Street 2:4863 N NEVADA AVE.
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918
Practice Address - Country:US
Practice Address - Phone:719-255-8003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2020-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY17721103T00000X
CO4424103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist