Healthcare Provider Details

I. General information

NPI: 1972052231
Provider Name (Legal Business Name): CHARLOTTE CRAWFORD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2016
Last Update Date: 09/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

863 S 239TH LN
BUCKEYE AZ
85326-8162
US

IV. Provider business mailing address

863 S 239TH LN
BUCKEYE AZ
85326-8162
US

V. Phone/Fax

Practice location:
  • Phone: 602-455-4626
  • Fax: 602-455-4624
Mailing address:
  • Phone: 602-455-4626
  • Fax: 602-455-4624

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code385HR2055X
TaxonomyChild Mental Illness Respite Care
License Number7289192
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: