Provider Demographics
NPI:1871942698
Name:KRAFT, DESIRAE
Entity type:Individual
Prefix:MS
First Name:DESIRAE
Middle Name:
Last Name:KRAFT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3876 BEVERLY AVE NE
Mailing Address - Street 2:BLDG G
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97305-1319
Mailing Address - Country:US
Mailing Address - Phone:503-763-5741
Mailing Address - Fax:
Practice Address - Street 1:3876 BEVERLY AVE NE
Practice Address - Street 2:BLDG G
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97305-1319
Practice Address - Country:US
Practice Address - Phone:503-763-5741
Practice Address - Fax:503-361-2728
Is Sole Proprietor?:No
Enumeration Date:2016-06-13
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist