Basic Information
| Provider Information | |||||||||
| NPI: | 1144528019 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CRAFT | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LISW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CRAFT | ||||||||
| OtherFirstName: | STEPHANIE | ||||||||
| OtherMiddleName: | L | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LISW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 941 MARKET STREET | ||||||||
| Address2: | |||||||||
| City: | PIKETON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456619757 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7402892371 | ||||||||
| FaxNumber: | 7402894291 | ||||||||
| Practice Location | |||||||||
| Address1: | 227 VALLEY VIEW DRIVE | ||||||||
| Address2: | |||||||||
| City: | WAVERLY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456909135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7409477726 | ||||||||
| FaxNumber: | 7409479354 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2011 | ||||||||
| LastUpdateDate: | 09/20/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | I.1100034-SUPV | OH | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 0270932 | 05 | OH | MEDICAID |