Provider Demographics
NPI:1043382971
Name:KRAGNESS, MIRIAM (PHD)
Entity Type:Individual
Prefix:
First Name:MIRIAM
Middle Name:
Last Name:KRAGNESS
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 1:301 E 17TH ST
Mailing Address - Street 2:REHABILITATION PSYCHOLOGY
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10003-3804
Mailing Address - Country:US
Mailing Address - Phone:212-598-3883
Mailing Address - Fax:212-598-6249
Practice Address - Street 1:301 E 17TH ST
Practice Address - Street 2:REHABILITATION PSYCHOLOGY
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-3804
Practice Address - Country:US
Practice Address - Phone:212-598-3883
Practice Address - Fax:212-598-6249
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2014-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015596-1103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN61-56492OtherMEDICA
MN113259OtherUCARE
MN522T5KROtherBLUECROSSBLUESHIELD
MN430057200Medicaid
MNHP48976OtherHEALTHPARTNERS
MN61-56492OtherMEDICA