Provider Demographics
NPI:1083982185
Name:CRADDOCK, GERALDINE BAKER (DMIN, LCADC, LPC)
Entity Type:Individual
Prefix:DR
First Name:GERALDINE
Middle Name:BAKER
Last Name:CRADDOCK
Suffix:
Gender:F
Credentials:DMIN, LCADC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1588 HILL RISE DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-2587
Mailing Address - Country:US
Mailing Address - Phone:859-255-0890
Mailing Address - Fax:859-255-0854
Practice Address - Street 1:1588 HILL RISE DR
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-2587
Practice Address - Country:US
Practice Address - Phone:859-255-0890
Practice Address - Fax:859-255-0854
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-05
Last Update Date:2016-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYADCLAD00225185324500000X
KYKY-0001324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1083982185Medicaid