Healthcare Provider Details

I. General information

NPI: 1164416749
Provider Name (Legal Business Name): KEVIN RICHARD KRACKE PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2005
Last Update Date: 03/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

422 17TH ST
LEWISTON ID
83501-2526
US

IV. Provider business mailing address

PO BOX 2145
LEWISTON ID
83501-1465
US

V. Phone/Fax

Practice location:
  • Phone: 208-743-4680
  • Fax: 208-743-1756
Mailing address:
  • Phone: 208-743-4680
  • Fax: 208-743-1756

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY189
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: