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General NPI Number Information
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NPI Number | 1851448781
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Entity Type | Organization
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Legal Business Name | DR. KRACKE AND ASSOCIATES P A
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Dates
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Enumeration Date | 01/04/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 422 17TH ST
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City | LEWISTON
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State | ID
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Zip | 83501-2526
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Country | US
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Telephone | 208-743-4680
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Fax | 208-743-1756
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Provider Business Mailing Address
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Address Line | PO BOX 2145
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City | LEWISTON
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State | ID
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Zip | 83501-1465
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Country | US
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Telephone | 208-743-4680
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Fax | 208-743-1756
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. KEVIN R. KRACKE
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Credential | PH.D.
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Telephone | 208-743-4680
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | PSY189
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License Number State | ID
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