Provider Demographics
NPI:1639491632
Name:CRAFT BEHAVIORAL HEALTH, LLC
Entity Type:Organization
Organization Name:CRAFT BEHAVIORAL HEALTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MOHAMMAD
Authorized Official - Middle Name:
Authorized Official - Last Name:FAROOQUE
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:904-379-5928
Mailing Address - Street 1:10175 FORTUNE PKWY
Mailing Address - Street 2:SUITE #1106
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-6746
Mailing Address - Country:US
Mailing Address - Phone:904-379-5928
Mailing Address - Fax:904-379-5967
Practice Address - Street 1:10175 FORTUNE PKWY
Practice Address - Street 2:SUITE #1106
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-6746
Practice Address - Country:US
Practice Address - Phone:904-379-5928
Practice Address - Fax:904-379-5967
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-18
Last Update Date:2011-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1455POtherBC/BS OF FL