Healthcare Provider Details

I. General information

NPI: 1538077102
Provider Name (Legal Business Name): CRAIG BARON HALVERSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2026
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1990 MCCULLOCH BLVD N STE D298
LAKE HAVASU CITY AZ
86403-5749
US

IV. Provider business mailing address

1990 MCCULLOCH BLVD N STE D298
LAKE HAVASU CITY AZ
86403-5749
US

V. Phone/Fax

Practice location:
  • Phone: 760-975-1300
  • Fax:
Mailing address:
  • Phone: 760-975-1300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: