Provider Demographics
NPI:1649788613
Name:KRAKOVICH, TERI MARISA (PHD)
Entity type:Individual
Prefix:DR
First Name:TERI
Middle Name:MARISA
Last Name:KRAKOVICH
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:PO BOX 392552
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15251-9500
Mailing Address - Country:US
Mailing Address - Phone:260-483-9081
Mailing Address - Fax:260-483-9196
Practice Address - Street 1:3512 STELLHORN RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46815-4631
Practice Address - Country:US
Practice Address - Phone:260-483-9081
Practice Address - Fax:260-483-9196
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-12
Last Update Date:2019-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20043109A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical