Basic Information
| Provider Information | |||||||||
| NPI: | 1144490681 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAMANN | ||||||||
| FirstName: | KRISTA | ||||||||
| MiddleName: | MARGUERITE | ||||||||
| NamePrefix: | |||||||||
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| Credential: | PH.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2655 RIDGEWAY AVE | ||||||||
| Address2: | SUITE 420 | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146264296 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5857237972 | ||||||||
| FaxNumber: | 5853683119 | ||||||||
| Practice Location | |||||||||
| Address1: | 2655 RIDGEWAY AVE | ||||||||
| Address2: | SUITE 420 | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146264296 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5857237972 | ||||||||
| FaxNumber: | 5853683119 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/11/2008 | ||||||||
| LastUpdateDate: | 09/28/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 09/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC1900X | 017575 | NY | N | Behavioral Health & Social Service Providers | Psychologist | Counseling | 103G00000X | 017575 | NY | Y | Behavioral Health & Social Service Providers | Clinical Neuropsychologist |
ID Information
| ID | Type | State | Issuer | Description | 03071074 | 05 | NY | MEDICAID |