Provider Demographics
NPI:1942911185
Name:GRAGG, KRYSTAL ELIZABETH
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:ELIZABETH
Last Name:GRAGG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KRYSTAL
Other - Middle Name:ELIZABETH
Other - Last Name:GAISBAUER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4119 SW 18TH CT
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97080-8344
Mailing Address - Country:US
Mailing Address - Phone:503-891-3696
Mailing Address - Fax:
Practice Address - Street 1:4101 NE DIVISION ST STE 100
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-4617
Practice Address - Country:US
Practice Address - Phone:503-666-3808
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-08
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor