Provider Demographics
NPI:1376573261
Name:KRACKOV, BETH
Entity Type:Individual
Prefix:DR
First Name:BETH
Middle Name:
Last Name:KRACKOV
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 WINFIELD ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94110-5141
Mailing Address - Country:US
Mailing Address - Phone:415-517-8865
Mailing Address - Fax:
Practice Address - Street 1:36 WINFIELD ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94110-5141
Practice Address - Country:US
Practice Address - Phone:415-517-8865
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2008-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY20522103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPL205221OtherMEDICARE ID-TYPE UNSPECIFIED
CAPSY205220Medicaid