Provider Demographics
NPI:1972863660
Name:BATES-CRADDOCK, LAVONNE RENAE
Entity Type:Individual
Prefix:
First Name:LAVONNE
Middle Name:RENAE
Last Name:BATES-CRADDOCK
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 1:3004 NW 68TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73116-3206
Mailing Address - Country:US
Mailing Address - Phone:405-837-4312
Mailing Address - Fax:
Practice Address - Street 1:3004 NW 68TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73116-3206
Practice Address - Country:US
Practice Address - Phone:405-837-4312
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-29
Last Update Date:2012-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst