Provider Demographics
NPI:1720368723
Name:DANBACK, KRISTINE FATZER (PHD)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:FATZER
Last Name:DANBACK
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 1:1511 ROUTE 22
Mailing Address - Street 2:SUITE 128
Mailing Address - City:BREWSTER
Mailing Address - State:NY
Mailing Address - Zip Code:10509-4020
Mailing Address - Country:US
Mailing Address - Phone:203-313-0032
Mailing Address - Fax:
Practice Address - Street 1:1511 ROUTE 22
Practice Address - Street 2:SUITE 128
Practice Address - City:BREWSTER
Practice Address - State:NY
Practice Address - Zip Code:10509-4020
Practice Address - Country:US
Practice Address - Phone:203-313-0032
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-22
Last Update Date:2014-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019055103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03361268Medicaid
NYAY00066858Medicare Oscar/Certification