Healthcare Provider Details

I. General information

NPI: 1366372583
Provider Name (Legal Business Name): CRAIG HENNECKE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/20/2026
Last Update Date: 05/20/2026
Certification Date: 05/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7870 BARLUM DR
INDIANAPOLIS IN
46240-2633
US

IV. Provider business mailing address

7870 BARLUM DR
INDIANAPOLIS IN
46240-2633
US

V. Phone/Fax

Practice location:
  • Phone: 503-475-1019
  • Fax:
Mailing address:
  • Phone: 503-475-1019
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number39006043A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: