Provider Demographics
NPI:1518303460
Name:CRAIG, MARK (LCPC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:CRAIG
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 W PIONEER PKWY
Mailing Address - Street 2:SUITE 20
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-1835
Mailing Address - Country:US
Mailing Address - Phone:309-258-6473
Mailing Address - Fax:
Practice Address - Street 1:2000 W PIONEER PKWY
Practice Address - Street 2:SUITE 20
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-1835
Practice Address - Country:US
Practice Address - Phone:309-258-6473
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-20
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.009303101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional