Provider Demographics
NPI:1154942340
Name:NORDSTROM, CRAIG ALLAN (PSYD, HSPP)
Entity type:Individual
Prefix:DR
First Name:CRAIG
Middle Name:ALLAN
Last Name:NORDSTROM
Suffix:
Gender:M
Credentials:PSYD, HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2344
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-5844
Mailing Address - Country:US
Mailing Address - Phone:219-628-3650
Mailing Address - Fax:844-364-4603
Practice Address - Street 1:111 E CLEARWATER AVE
Practice Address - Street 2:
Practice Address - City:BEVERLY SHORES
Practice Address - State:IN
Practice Address - Zip Code:46301-0056
Practice Address - Country:US
Practice Address - Phone:219-628-3650
Practice Address - Fax:844-364-4603
Is Sole Proprietor?:No
Enumeration Date:2020-04-29
Last Update Date:2020-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20041303A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical