Healthcare Provider Details

I. General information

NPI: 1710286653
Provider Name (Legal Business Name): CARI RENEE MCCRACKEN CADC - CAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/17/2011
Last Update Date: 10/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2844 COLOMA ST
PLACERVILLE CA
95667-4406
US

IV. Provider business mailing address

PO BOX 586
CAMINO CA
95709-0586
US

V. Phone/Fax

Practice location:
  • Phone: 530-626-9240
  • Fax: 530-626-8992
Mailing address:
  • Phone: 530-626-9240
  • Fax: 530-644-3782

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number03107172
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberC057370618
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: