=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003109265
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CARRIE CRAVENS LSCW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/20/2011
-----------------------------------------------------
Last Update Date | 08/21/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6900 ALDEN DR
-----------------------------------------------------
City | FE WARREN AFB
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82005-2945
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-773-4337
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6900 ALDEN DR
-----------------------------------------------------
City | FE WARREN AFB
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82005-2945
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-773-4337
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 0904015092
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 2019010079
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------