Provider Demographics
NPI:1346545878
Name:CRAIG-VAN GRACK, AMY (LCSW-C)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:CRAIG-VAN GRACK
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1680 E GUDE DR
Mailing Address - Street 2:STE 112
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-5360
Mailing Address - Country:US
Mailing Address - Phone:240-483-3873
Mailing Address - Fax:301-399-0523
Practice Address - Street 1:1680 E GUDE DR
Practice Address - Street 2:SUITE 112
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-1360
Practice Address - Country:US
Practice Address - Phone:240-483-3873
Practice Address - Fax:240-558-3854
Is Sole Proprietor?:No
Enumeration Date:2011-01-13
Last Update Date:2016-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD126651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD53398000Medicaid
MD53398000Medicaid