Provider Demographics
NPI:1104200740
Name:CRAIG, TRISTAM (SST)
Entity type:Individual
Prefix:
First Name:TRISTAM
Middle Name:
Last Name:CRAIG
Suffix:
Gender:M
Credentials:SST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:585 JEWETT RD
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:MI
Mailing Address - Zip Code:48854-8729
Mailing Address - Country:US
Mailing Address - Phone:517-676-5405
Mailing Address - Fax:
Practice Address - Street 1:4400 S SAGINAW ST STE 1460
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48507-2664
Practice Address - Country:US
Practice Address - Phone:810-237-0799
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-14
Last Update Date:2015-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6803086719171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator