Provider Demographics
NPI:1285177410
Name:CRADDOCK, MICHAEL MARVIN THOMAS (MED)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:MARVIN THOMAS
Last Name:CRADDOCK
Suffix:
Gender:M
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 N LESLIE ST
Mailing Address - Street 2:
Mailing Address - City:ANACONDA
Mailing Address - State:MT
Mailing Address - Zip Code:59711-9304
Mailing Address - Country:US
Mailing Address - Phone:406-565-3094
Mailing Address - Fax:
Practice Address - Street 1:5 N LESLIE ST
Practice Address - Street 2:
Practice Address - City:ANACONDA
Practice Address - State:MT
Practice Address - Zip Code:59711-9304
Practice Address - Country:US
Practice Address - Phone:406-565-3094
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-20
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-LCPC-LIC-19613101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional