Provider Demographics
NPI:1124577986
Name:MYCRACO LLC
Entity Type:Organization
Organization Name:MYCRACO LLC
Other - Org Name:MYCRACO LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:COENEN
Authorized Official - Suffix:
Authorized Official - Credentials:DR
Authorized Official - Phone:417-315-4962
Mailing Address - Street 1:1238 TYLER LN
Mailing Address - Street 2:
Mailing Address - City:NIXA
Mailing Address - State:MO
Mailing Address - Zip Code:65714-8368
Mailing Address - Country:US
Mailing Address - Phone:417-315-4962
Mailing Address - Fax:888-884-4101
Practice Address - Street 1:2053 S WAVERLY AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2414
Practice Address - Country:US
Practice Address - Phone:417-315-4962
Practice Address - Fax:888-884-4101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-22
Last Update Date:2016-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010024663101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1821137159Medicaid