Provider Demographics
NPI:1144490681
Name:DAMANN, KRISTA MARGUERITE (PHD)
Entity type:Individual
Prefix:
First Name:KRISTA
Middle Name:MARGUERITE
Last Name:DAMANN
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 1:2655 RIDGEWAY AVE
Mailing Address - Street 2:SUITE 420
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14626-4296
Mailing Address - Country:US
Mailing Address - Phone:585-723-7972
Mailing Address - Fax:585-368-3119
Practice Address - Street 1:2655 RIDGEWAY AVE
Practice Address - Street 2:SUITE 420
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14626-4296
Practice Address - Country:US
Practice Address - Phone:585-723-7972
Practice Address - Fax:585-368-3119
Is Sole Proprietor?:No
Enumeration Date:2008-03-11
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017575103TC1900X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03071074Medicaid
NY03071074Medicaid
NYJ400059164/GP BA0017Medicare PIN