Provider Demographics
NPI:1174938518
Name:CROCKHAM, CARL
Entity type:Individual
Prefix:
First Name:CARL
Middle Name:
Last Name:CROCKHAM
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 1:4325 W ROME BLVD APT 1184
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89084-5409
Mailing Address - Country:US
Mailing Address - Phone:702-561-0866
Mailing Address - Fax:
Practice Address - Street 1:4325 W ROME BLVD APT 1184
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89084-5409
Practice Address - Country:US
Practice Address - Phone:702-561-0866
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-24
Last Update Date:2014-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty