Provider Demographics
NPI:1225393267
Name:KRAGT, MICHAEL TODD (PHD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:TODD
Last Name:KRAGT
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 FORTINO BLVD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-1664
Mailing Address - Country:US
Mailing Address - Phone:719-544-4111
Mailing Address - Fax:719-544-3497
Practice Address - Street 1:1515 FORTINO BLVD
Practice Address - Street 2:SUITE 120
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-1664
Practice Address - Country:US
Practice Address - Phone:719-544-4111
Practice Address - Fax:719-544-3497
Is Sole Proprietor?:No
Enumeration Date:2012-07-05
Last Update Date:2012-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5177101YA0400X
CO2188103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical