Provider Demographics
NPI:1578823589
Name:MCCRACKEN, STEWART ANDREW (LAC)
Entity Type:Individual
Prefix:
First Name:STEWART
Middle Name:ANDREW
Last Name:MCCRACKEN
Suffix:
Gender:M
Credentials:LAC
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 124
Mailing Address - Street 2:
Mailing Address - City:SUPERIOR
Mailing Address - State:MT
Mailing Address - Zip Code:59872-0124
Mailing Address - Country:US
Mailing Address - Phone:406-304-6371
Mailing Address - Fax:866-261-3089
Practice Address - Street 1:491 SHAW GULCH LN
Practice Address - Street 2:
Practice Address - City:SUPERIOR
Practice Address - State:MT
Practice Address - Zip Code:59872-0124
Practice Address - Country:US
Practice Address - Phone:406-304-6371
Practice Address - Fax:866-261-3089
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-23
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1951101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1265066500Medicaid