Provider Demographics
NPI:1629177423
Name:CRADDOCK, LOUIS RAY (MS)
Entity Type:Individual
Prefix:MR
First Name:LOUIS
Middle Name:RAY
Last Name:CRADDOCK
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 SENECA DR
Mailing Address - Street 2:
Mailing Address - City:BELPRE
Mailing Address - State:OH
Mailing Address - Zip Code:45714-1141
Mailing Address - Country:US
Mailing Address - Phone:740-423-4707
Mailing Address - Fax:740-423-6976
Practice Address - Street 1:800 SENECA DR
Practice Address - Street 2:
Practice Address - City:BELPRE
Practice Address - State:OH
Practice Address - Zip Code:45714-1141
Practice Address - Country:US
Practice Address - Phone:740-423-4707
Practice Address - Fax:740-423-6976
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV670103TA0400X, 103TC0700X, 103TF0200X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0164801000Medicaid