Provider Demographics
NPI:1558905992
Name:CRAVEN, EDWARD PATRICK JR
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:PATRICK
Last Name:CRAVEN
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2810 NORTHPLACE WAY SE
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080-8615
Mailing Address - Country:US
Mailing Address - Phone:678-938-8852
Mailing Address - Fax:
Practice Address - Street 1:3745 CHEROKEE ST NW STE 607
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-6733
Practice Address - Country:US
Practice Address - Phone:770-499-0140
Practice Address - Fax:770-499-0147
Is Sole Proprietor?:No
Enumeration Date:2019-10-29
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA010637101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional