Basic Information
Provider Information | |||||||||
NPI: | 1356881924 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KRIGBAUM | ||||||||
FirstName: | GENOMARY | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MA, PSYD, BCB, LP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | KRIGBAUM-PEREZ | ||||||||
OtherFirstName: | GENOMARY | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MA, PSYD, BCB, LP | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 16279 | ||||||||
Address2: |   | ||||||||
City: | GOLDEN | ||||||||
State: | CO | ||||||||
PostalCode: | 804026005 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1111 E END BLVD | ||||||||
Address2: |   | ||||||||
City: | WILKES BARRE | ||||||||
State: | PA | ||||||||
PostalCode: | 18711 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5708243521 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/02/2017 | ||||||||
LastUpdateDate: | 08/14/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103G00000X | LP6138 | MN | N |   | Behavioral Health & Social Service Providers | Clinical Neuropsychologist |   | 103G00000X | 005680 | PR | N |   | Behavioral Health & Social Service Providers | Clinical Neuropsychologist |   | 103T00000X | LP6138 | MN | N |   | Behavioral Health & Social Service Providers | Psychologist |   | 103T00000X | 669 | WY | N |   | Behavioral Health & Social Service Providers | Psychologist |   | 103T00000X | 005680 | PR | N |   | Behavioral Health & Social Service Providers | Psychologist |   | 103TC0700X | 005680 | PR | N |   | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC0700X | LP6138 | MN | N |   | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC0700X | 669 | WY | N |   | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TH0004X | LP6138 | MN | N |   | Behavioral Health & Social Service Providers | Psychologist | Health | 103TH0004X | 005680 | PR | N |   | Behavioral Health & Social Service Providers | Psychologist | Health | 103TH0004X | 669 | WY | N |   | Behavioral Health & Social Service Providers | Psychologist | Health | 103G00000X | 669 | WY | Y |   | Behavioral Health & Social Service Providers | Clinical Neuropsychologist |   |
No ID Information.