Provider Demographics
NPI:1902822703
Name:CRAIG, SUSAN
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:CRAIG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 W COLONIAL DR
Mailing Address - Street 2:SUITE 302
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-6863
Mailing Address - Country:US
Mailing Address - Phone:407-362-6003
Mailing Address - Fax:407-362-6007
Practice Address - Street 1:425 W COLONIAL DR
Practice Address - Street 2:SUITE 302
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32804-6863
Practice Address - Country:US
Practice Address - Phone:407-362-6003
Practice Address - Fax:407-362-6007
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2009-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH 9422101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6103037Medicaid