Provider Demographics
NPI:1710286653
Name:MCCRACKEN, CARI RENEE (CADC - CAS)
Entity Type:Individual
Prefix:
First Name:CARI
Middle Name:RENEE
Last Name:MCCRACKEN
Suffix:
Gender:F
Credentials:CADC - CAS
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 586
Mailing Address - Street 2:
Mailing Address - City:CAMINO
Mailing Address - State:CA
Mailing Address - Zip Code:95709-0586
Mailing Address - Country:US
Mailing Address - Phone:530-626-9240
Mailing Address - Fax:530-644-3782
Practice Address - Street 1:2844 COLOMA ST
Practice Address - Street 2:
Practice Address - City:PLACERVILLE
Practice Address - State:CA
Practice Address - Zip Code:95667-4406
Practice Address - Country:US
Practice Address - Phone:530-626-9240
Practice Address - Fax:530-626-8992
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-17
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA03107172174400000X
CAC057370618101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA03107172OtherCERTIFIED ALCOHOL AND DRUG SPECIALIST