Provider Demographics
NPI:1396732236
Name:IVERSEN, CRAIG (PHD)
Entity type:Individual
Prefix:
First Name:CRAIG
Middle Name:
Last Name:IVERSEN
Suffix:
Gender:M
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:PO BOX 1149
Mailing Address - Street 2:
Mailing Address - City:NEBO
Mailing Address - State:NC
Mailing Address - Zip Code:28761-0964
Mailing Address - Country:US
Mailing Address - Phone:828-257-3226
Mailing Address - Fax:910-791-6890
Practice Address - Street 1:1251 PINNACLE CHURCH ROAD
Practice Address - Street 2:
Practice Address - City:NEBO
Practice Address - State:NC
Practice Address - Zip Code:28761
Practice Address - Country:US
Practice Address - Phone:828-257-3115
Practice Address - Fax:910-791-6890
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0520103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0344HOtherBLUE CROSS BLUE SHIELD
61-00172OtherEVERCARE
NC6000640Medicaid
NC6000640Medicaid
680011940Medicare PIN