Provider Demographics
NPI:1396296315
Name:CRADDOCK, CASEY (LAT, MAT, ATC)
Entity type:Individual
Prefix:
First Name:CASEY
Middle Name:
Last Name:CRADDOCK
Suffix:
Gender:M
Credentials:LAT, MAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1540 MORRISON ST
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53703-3816
Mailing Address - Country:US
Mailing Address - Phone:970-518-9071
Mailing Address - Fax:
Practice Address - Street 1:1475 ENGINEERING DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53706-1607
Practice Address - Country:US
Practice Address - Phone:608-440-0363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-14
Last Update Date:2016-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI19122255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer