Basic Information
Provider Information | |||||||||
NPI: | 1871596023 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KRONSNOBLE | ||||||||
FirstName: | KRISTIN | ||||||||
MiddleName: | M | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PH.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1289 | ||||||||
Address2: |   | ||||||||
City: | TAMPA | ||||||||
State: | FL | ||||||||
PostalCode: | 336011289 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8132518017 | ||||||||
FaxNumber: | 8132510096 | ||||||||
Practice Location | |||||||||
Address1: | 409 BAYSHORE BLVD | ||||||||
Address2: |   | ||||||||
City: | TAMPA | ||||||||
State: | FL | ||||||||
PostalCode: | 336062707 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8132518017 | ||||||||
FaxNumber: | 8132510096 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/23/2005 | ||||||||
LastUpdateDate: | 06/11/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/11/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | PY5454 | FL | N |   | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TH0100X | PSY002071 | GA | N |   | Behavioral Health & Social Service Providers | Psychologist | Health Service | 103TH0100X | PY5454 | FL | N |   | Behavioral Health & Social Service Providers | Psychologist | Health Service | 103T00000X | PY5454 | FL | Y |   | Behavioral Health & Social Service Providers | Psychologist |   |
ID Information
ID | Type | State | Issuer | Description | 212084400 | 05 | FL |   | MEDICAID |