Provider Demographics
NPI:1508124835
Name:KRACKE, FREDERICK LEE JR
Entity Type:Individual
Prefix:MR
First Name:FREDERICK
Middle Name:LEE
Last Name:KRACKE
Suffix:JR
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:GIL
Other - Middle Name:
Other - Last Name:KRACKE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA, MA, LPC
Mailing Address - Street 1:3512 OLD LEEDS CRST
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN BRK
Mailing Address - State:AL
Mailing Address - Zip Code:35213-3220
Mailing Address - Country:US
Mailing Address - Phone:205-879-2166
Mailing Address - Fax:
Practice Address - Street 1:2204 LAKESHORE DR
Practice Address - Street 2:SUITE 212
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35209-6729
Practice Address - Country:US
Practice Address - Phone:205-879-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-24
Last Update Date:2012-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3000101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional