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General NPI Number Information
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NPI Number | 1225393267
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Entity Type | Individual
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Provider Name | MICHAEL TODD KRAGT PHD
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Gender | Male
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Dates
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Enumeration Date | 07/05/2012
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Last Update Date | 07/05/2012
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Provider Practice Location Address
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Address Line | 1515 FORTINO BLVD SUITE 120
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City | PUEBLO
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State | CO
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Zip | 81008-1664
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Country | US
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Telephone | 719-544-4111
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Fax | 719-544-3497
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Provider Business Mailing Address
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Address Line | 1515 FORTINO BLVD SUITE 120
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City | PUEBLO
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State | CO
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Zip | 81008-1664
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Country | US
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Telephone | 719-544-4111
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Fax | 719-544-3497
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 5177
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License Number State | CO
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Taxonomy #2
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 2188
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License Number State | CO
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