Provider Demographics
NPI:1356881924
Name:KRIGBAUM, GENOMARY (MA, PSYD, BCB, LP)
Entity type:Individual
Prefix:DR
First Name:GENOMARY
Middle Name:
Last Name:KRIGBAUM
Suffix:
Gender:F
Credentials:MA, PSYD, BCB, LP
Other - Prefix:DR
Other - First Name:GENOMARY
Other - Middle Name:
Other - Last Name:KRIGBAUM-PEREZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA, PSYD, BCB, LP
Mailing Address - Street 1:PO BOX 16279
Mailing Address - Street 2:
Mailing Address - City:GOLDEN
Mailing Address - State:CO
Mailing Address - Zip Code:80402-6005
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1111 E END BLVD
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18711
Practice Address - Country:US
Practice Address - Phone:570-824-3521
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-02
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP6138103G00000X, 103T00000X, 103TC0700X, 103TH0004X
PR005680103G00000X, 103T00000X, 103TC0700X, 103TH0004X
WY669103T00000X, 103TC0700X, 103TH0004X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth