Provider Demographics
NPI:1194438598
Name:CRAVEN, AMY BETH (LADC I)
Entity type:Individual
Prefix:
First Name:AMY BETH
Middle Name:
Last Name:CRAVEN
Suffix:
Gender:F
Credentials:LADC I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1183 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01603-2012
Mailing Address - Country:US
Mailing Address - Phone:508-834-8599
Mailing Address - Fax:
Practice Address - Street 1:1183 MAIN ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01603-2012
Practice Address - Country:US
Practice Address - Phone:508-986-9480
Practice Address - Fax:508-796-2273
Is Sole Proprietor?:No
Enumeration Date:2022-12-30
Last Update Date:2022-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA21320101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1144769167Medicaid