Healthcare Provider Details

I. General information

NPI: 1891945705
Provider Name (Legal Business Name): CRAIG PROFESSIONAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2008
Last Update Date: 10/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 PINE AVE
WACO TX
76708-3142
US

IV. Provider business mailing address

3300 PINE AVE
WACO TX
76708-3142
US

V. Phone/Fax

Practice location:
  • Phone: 254-855-5103
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number17012
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number32607
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number51927
License Number StateTX

VIII. Authorized Official

Name: MR. JASON CRAIG
Title or Position: LICENSED PROFESSIONAL COUNSELOR
Credential: LPC
Phone: 254-855-5103