Healthcare Provider Details

I. General information

NPI: 1851448781
Provider Name (Legal Business Name): DR. KRACKE AND ASSOCIATES P A
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
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 TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberPSY189
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. KEVIN R. KRACKE
Title or Position: PRESIDENT
Credential: PH.D.
Phone: 208-743-4680