Provider Demographics
NPI:1962752097
Name:CRAFT, ANTHONY TYRONNE
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:TYRONNE
Last Name:CRAFT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 MORNINGHILL DR
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29115-7791
Mailing Address - Country:US
Mailing Address - Phone:803-387-2792
Mailing Address - Fax:
Practice Address - Street 1:2319 SAINT MATTHEWS RD
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29118-2042
Practice Address - Country:US
Practice Address - Phone:803-536-1571
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-17
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC413093Medicaid