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NPI Code Detail

MEDICARE: HOLLY CRADER MAADCII, MARS

MEDICARE: HOLLY CRADER MAADCII, MARS
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1101YA0400XAddiction (Substance Use Disorder) Counselor

General Provider Information

NPI Number : 1629532098
Entity Type Code : Individual
Provider Name (Legal Business Name) : HOLLY CRADER MAADCII, MARS
Provider Business Mailing Address
First Line : 760 S KINGSHIGHWAY ST STE F
Second Line :
City : CAPE GIRARDEAU
State : MO
Zip : 63703-7676
Country : US
Telephone Number : 573-335-4333
Fax Number : 573-335-4345
Provider Business Practice Location Address
First Line : 760 S KINGSHIGHWAY ST STE F
Second Line :
City : CAPE GIRARDEAU
State : MO
Zip : 63703-7676
Country : US
Telephone Number : 573-335-4333
Fax Number : 573-335-4345
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/30/2019
Last Update Date : 01/30/2019

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