Provider Demographics
NPI:1407993934
Name:MACCRACKEN, JOAN (LCSW)
Entity Type:Individual
Prefix:MS
First Name:JOAN
Middle Name:
Last Name:MACCRACKEN
Suffix:
Gender:F
Credentials:LCSW
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 325
Mailing Address - Street 2:
Mailing Address - City:ARROYO SECO
Mailing Address - State:NM
Mailing Address - Zip Code:87514-0325
Mailing Address - Country:US
Mailing Address - Phone:575-770-3126
Mailing Address - Fax:888-827-0978
Practice Address - Street 1:125 LA POSTA RD STE 6
Practice Address - Street 2:
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-7242
Practice Address - Country:US
Practice Address - Phone:575-770-3126
Practice Address - Fax:888-827-0978
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM -05383104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM91385547Medicaid