Provider Demographics
NPI:1366946378
Name:MCCRACKEN, MICHAELA GEORGETTE (EDS)
Entity type:Individual
Prefix:
First Name:MICHAELA
Middle Name:GEORGETTE
Last Name:MCCRACKEN
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2801 TURNPIKE RD
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23707-4630
Mailing Address - Country:US
Mailing Address - Phone:757-393-8766
Mailing Address - Fax:757-393-5129
Practice Address - Street 1:2801 TURNPIKE RD
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23707-4630
Practice Address - Country:US
Practice Address - Phone:757-393-8766
Practice Address - Fax:757-393-5129
Is Sole Proprietor?:No
Enumeration Date:2018-03-23
Last Update Date:2018-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAPPS-358239103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool