Provider Demographics
NPI:1164605549
Name:CRADDOCK, TERRY LEE (LMT, LPN)
Entity Type:Individual
Prefix:MR
First Name:TERRY
Middle Name:LEE
Last Name:CRADDOCK
Suffix:
Gender:M
Credentials:LMT, LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FARMER CITY
Mailing Address - State:IL
Mailing Address - Zip Code:61842-1454
Mailing Address - Country:US
Mailing Address - Phone:309-824-4373
Mailing Address - Fax:
Practice Address - Street 1:120 S MAIN ST
Practice Address - Street 2:
Practice Address - City:FARMER CITY
Practice Address - State:IL
Practice Address - Zip Code:61842-1454
Practice Address - Country:US
Practice Address - Phone:309-824-4373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-09
Last Update Date:2008-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist