Provider Demographics
NPI:1316085954
Name:CRADOCK, CARROLL A (PHD)
Entity type:Individual
Prefix:DR
First Name:CARROLL
Middle Name:A
Last Name:CRADOCK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 S SANGAMON ST
Mailing Address - Street 2:SUITE 2A
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-3547
Mailing Address - Country:US
Mailing Address - Phone:312-243-7441
Mailing Address - Fax:
Practice Address - Street 1:411 S SANGAMON ST
Practice Address - Street 2:SUITE 2A
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60607-3547
Practice Address - Country:US
Practice Address - Phone:312-243-7441
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TC2200X
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical