Provider Demographics
NPI:1295431898
Name:CRAFT, AVIAN MILDREE
Entity type:Individual
Prefix:
First Name:AVIAN
Middle Name:MILDREE
Last Name:CRAFT
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 1:912 LOVVORN RD
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-2635
Mailing Address - Country:US
Mailing Address - Phone:706-436-9630
Mailing Address - Fax:
Practice Address - Street 1:912 LOVVORN RD APT 1131
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-2648
Practice Address - Country:US
Practice Address - Phone:706-436-9630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-06
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA106S00000XOtherBEHAVIOR TECHNICIAN