Provider Demographics
NPI:1639941768
Name:ROOF, KRISTEN ANN (MED, CAGS)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:ANN
Last Name:ROOF
Suffix:
Gender:F
Credentials:MED, CAGS
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:ANN
Other - Last Name:MULLEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MED CAGS
Mailing Address - Street 1:1900 PURDY AVE APT 1910
Mailing Address - Street 2:
Mailing Address - City:MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33139-1492
Mailing Address - Country:US
Mailing Address - Phone:203-434-0266
Mailing Address - Fax:
Practice Address - Street 1:1900 PURDY AVE
Practice Address - Street 2:
Practice Address - City:MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33139-1400
Practice Address - Country:US
Practice Address - Phone:203-434-0266
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-23
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA312149103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool