1508811464 NPI number — TERRY DIANE CROTINGER LPC

Table of content: TERRY DIANE CROTINGER LPC (NPI 1508811464)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508811464 NPI number — TERRY DIANE CROTINGER LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CROTINGER
Provider First Name:
TERRY
Provider Middle Name:
DIANE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CROTINGER
Provider Other First Name:
TERRY
Provider Other Middle Name:
D
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LPCC
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1508811464
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/04/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1396
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RATON
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87740-1396
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-707-2257
Provider Business Mailing Address Fax Number:
888-972-3649

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
250 PARK AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RATON
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87740
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-707-2257
Provider Business Practice Location Address Fax Number:
888-972-3649
Provider Enumeration Date:
05/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  LPC1658 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X , with the licence number: LPCC 0159381 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 002479 . This is a "AHCCCS" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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