Provider Demographics
NPI:1528781960
Name:CRAIG, IVANNA ANTONINA (LCSW)
Entity type:Individual
Prefix:MRS
First Name:IVANNA
Middle Name:ANTONINA
Last Name:CRAIG
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4325 JACINTHE CT
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95356-9775
Mailing Address - Country:US
Mailing Address - Phone:209-484-6745
Mailing Address - Fax:
Practice Address - Street 1:4325 JACINTHE CT
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95356-9775
Practice Address - Country:US
Practice Address - Phone:209-484-6745
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-21
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW256061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical