Healthcare Provider Details

I. General information

NPI: 1356896930
Provider Name (Legal Business Name): ILANA CRADDOCK LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ILANA DERENFELD

II. Dates (important events)

Enumeration Date: 08/24/2016
Last Update Date: 08/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 E WASHINGTON ST
EAST PEORIA IL
61611-2663
US

IV. Provider business mailing address

1626 JADENS WAY
WASHINGTON IL
61571-4601
US

V. Phone/Fax

Practice location:
  • Phone: 309-282-6704
  • Fax: 309-387-2340
Mailing address:
  • Phone: 847-909-5457
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149014751
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: