Basic Information
| Provider Information | |||||||||
| NPI: | 1003013053 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ENGEL | ||||||||
| FirstName: | KRISTIE | ||||||||
| MiddleName: | DAWN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MADDEN | ||||||||
| OtherFirstName: | KRISTIE | ||||||||
| OtherMiddleName: | ENGEL | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PHD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 2135 | ||||||||
| Address2: | |||||||||
| City: | CEDAR PARK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786302135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5125724673 | ||||||||
| FaxNumber: | 5123556737 | ||||||||
| Practice Location | |||||||||
| Address1: | 11701 BEE CAVES RD STE 213 | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787386468 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5125724673 | ||||||||
| FaxNumber: | 5123556737 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2007 | ||||||||
| LastUpdateDate: | 11/02/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TP2701X | 33629 | TX | N | Behavioral Health & Social Service Providers | Psychologist | Group Psychotherapy | 103TC2200X | 33629 | TX | N | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent | 103TC0700X | 33629 | TX | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 1003013053 | 05 | TX | MEDICAID | 33629 | 01 | TX | TX STATE BOARD OF EXAMINERS OF PSYCHOLOGISTS | OTHER |