Provider Demographics
NPI:1033745195
Name:CRAYCRAFT, MACKENZIE B (CDCA)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:B
Last Name:CRAYCRAFT
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 ELSINORE PL STE 200
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45202-1457
Mailing Address - Country:US
Mailing Address - Phone:833-510-4357
Mailing Address - Fax:866-460-2997
Practice Address - Street 1:1405 11TH ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:OH
Practice Address - Zip Code:45662-4203
Practice Address - Country:US
Practice Address - Phone:833-510-4357
Practice Address - Fax:866-460-2997
Is Sole Proprietor?:No
Enumeration Date:2020-03-20
Last Update Date:2021-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.176405101YA0400X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0395463Medicaid