Provider Demographics
NPI:1124717202
Name:CRADDICK, CLAIRE
Entity type:Individual
Prefix:
First Name:CLAIRE
Middle Name:
Last Name:CRADDICK
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 1:5500 UNIVERSITY PKWY
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92407-2318
Mailing Address - Country:US
Mailing Address - Phone:909-537-5040
Mailing Address - Fax:
Practice Address - Street 1:9135 ARCHIBALD AVE STE B
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-5227
Practice Address - Country:US
Practice Address - Phone:424-272-1806
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-03
Last Update Date:2024-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA120675101YM0800X
CA149648106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health