Provider Demographics
NPI:1447527296
Name:CRADDOCK, KATIE R
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:R
Last Name:CRADDOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31606 N.E. PINK HILL ROAD
Mailing Address - Street 2:PO BOX 304
Mailing Address - City:GRAIN VALLEY
Mailing Address - State:MO
Mailing Address - Zip Code:64029-0304
Mailing Address - Country:US
Mailing Address - Phone:816-847-5006
Mailing Address - Fax:816-229-4831
Practice Address - Street 1:31606 N.E. PINK HILL ROAD
Practice Address - Street 2:
Practice Address - City:GRAIN VALLEY
Practice Address - State:MO
Practice Address - Zip Code:64029-0304
Practice Address - Country:US
Practice Address - Phone:816-847-5006
Practice Address - Fax:816-229-4831
Is Sole Proprietor?:No
Enumeration Date:2011-11-22
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011034018235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist