Provider Demographics
NPI:1902029481
Name:KRACKER, LAURA MARIE (MA LIMITED LICENSE)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:MARIE
Last Name:KRACKER
Suffix:
Gender:F
Credentials:MA LIMITED LICENSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 W SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-4711
Mailing Address - Country:US
Mailing Address - Phone:269-349-4219
Mailing Address - Fax:269-349-5107
Practice Address - Street 1:122 W SOUTH ST
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-4711
Practice Address - Country:US
Practice Address - Phone:269-349-4219
Practice Address - Fax:269-349-5107
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301011342103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6301011342OtherLIMITED LICENSE PSYCHOLOG