Healthcare Provider Details

I. General information

NPI: 1538566690
Provider Name (Legal Business Name): KEVIN CREAGER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/04/2014
Last Update Date: 12/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 W PLEASANT ST
SPRINGFIELD OH
45506-2278
US

IV. Provider business mailing address

920 SANTA MONICA AVE
SPRINGFIELD OH
45503-1317
US

V. Phone/Fax

Practice location:
  • Phone: 937-767-7217
  • Fax:
Mailing address:
  • Phone: 937-767-7217
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberSP416
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: