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NPI Code Detail

MEDICARE: AVERY MARIE CRADDOCK MS

MEDICARE: AVERY MARIE CRADDOCK MS
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1101YM0800XMental Health Counselor0704017258VA

General Provider Information

NPI Number : 1174411797
Entity Type Code : Individual
Provider Name (Legal Business Name) : AVERY MARIE CRADDOCK MS
Provider Business Mailing Address
First Line : 5900 PATTERSON AVE APT 1
Second Line :
City : RICHMOND
State : VA
Zip : 23226-2551
Country : US
Telephone Number : 804-317-8659
Fax Number :
Provider Business Practice Location Address
First Line : 4337 COX RD
Second Line :
City : GLEN ALLEN
State : VA
Zip : 23060-3359
Country : US
Telephone Number : 804-277-9877
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/24/2025
Last Update Date : 06/25/2025

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