Provider Demographics
NPI:1962218586
Name:CRADDOCK, CHARLES A III
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:A
Last Name:CRADDOCK
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5135 E 112TH ST
Mailing Address - Street 2:
Mailing Address - City:GARFIELD HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44125-2729
Mailing Address - Country:US
Mailing Address - Phone:216-278-4717
Mailing Address - Fax:
Practice Address - Street 1:5135 E 112TH ST
Practice Address - Street 2:
Practice Address - City:GARFIELD HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44125-2729
Practice Address - Country:US
Practice Address - Phone:216-278-4717
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-09
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services