Provider Demographics
NPI:1942401229
Name:CROCK, AMY SUE (MA CCC-SLP)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:SUE
Last Name:CROCK
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:SUE
Other - Last Name:DUSENBERRY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA CCC-SLP
Mailing Address - Street 1:11955 NORFIELD RD
Mailing Address - Street 2:
Mailing Address - City:NEW CONCORD
Mailing Address - State:OH
Mailing Address - Zip Code:43762-9755
Mailing Address - Country:US
Mailing Address - Phone:440-479-2524
Mailing Address - Fax:
Practice Address - Street 1:11955 NORFIELD RD
Practice Address - Street 2:
Practice Address - City:NEW CONCORD
Practice Address - State:OH
Practice Address - Zip Code:43762-9755
Practice Address - Country:US
Practice Address - Phone:440-479-2524
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-31
Last Update Date:2014-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP 6285282NR1301X, 282NR1301X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NR1301XHospitalsGeneral Acute Care HospitalRural
Not Answered314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility