Healthcare Provider Details

I. General information

NPI: 1235725144
Provider Name (Legal Business Name): TED CRAVENS PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2020
Last Update Date: 12/15/2020
Certification Date: 12/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 E LOOP RD
WHEATON IL
60189-1938
US

IV. Provider business mailing address

2948 ARTESIAN RD STE 112
NAPERVILLE IL
60564-8559
US

V. Phone/Fax

Practice location:
  • Phone: 630-428-7890
  • Fax:
Mailing address:
  • Phone: 630-428-7890
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071006105
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: