Individual
DR. KEVIN RICHARD KRACKE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PH.D.
Contact information
Practice address
422 17TH ST, LEWISTON, ID 83501-2526
(208) 743-4680
(208) 743-1756
Mailing address
PO BOX 2145, LEWISTON, ID 83501-1465
(208) 743-4680
(208) 743-1756
Taxonomy
Speciality
Code
Description
License number
State
103T00000X
Psychologist
Primary
PSY189
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000010015963
BLUESHIELD OF IDAHO
ID
05
—
806177700
—
ID
01
—
N4478
BLUE CROSS OF IDAHO
ID
Enumeration date
09/09/2005
Last updated
03/15/2013
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