Provider Demographics
NPI:1164416749
Name:KRACKE, KEVIN RICHARD (PHD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:RICHARD
Last Name:KRACKE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2145
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-1465
Mailing Address - Country:US
Mailing Address - Phone:208-743-4680
Mailing Address - Fax:208-743-1756
Practice Address - Street 1:422 17TH ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-2526
Practice Address - Country:US
Practice Address - Phone:208-743-4680
Practice Address - Fax:208-743-1756
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2013-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSY189103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDN4478OtherBLUE CROSS OF IDAHO
ID000010015963OtherBLUESHIELD OF IDAHO
ID806177700Medicaid
IDN4478OtherBLUE CROSS OF IDAHO