Provider Demographics
NPI:1811388424
Name:KRECEK, JOHN ANTHONY (MA,CAADC, MATS, CCJP)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ANTHONY
Last Name:KRECEK
Suffix:
Gender:M
Credentials:MA,CAADC, MATS, CCJP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12173 SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:SAWYER
Mailing Address - State:MI
Mailing Address - Zip Code:49125-9155
Mailing Address - Country:US
Mailing Address - Phone:269-985-3151
Mailing Address - Fax:
Practice Address - Street 1:4218 W WESTERN AVE
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46619-2622
Practice Address - Country:US
Practice Address - Phone:574-233-1524
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-18
Last Update Date:2015-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL32436101YA0400X
INMATS-148101YA0400X
INCCJP-1005101YA0400X
INCIV-1710101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0Medicaid
IN0Medicaid