Healthcare Provider Details

I. General information

NPI: 1215217633
Provider Name (Legal Business Name): MR. IAN TERRY CROCKER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2011
Last Update Date: 08/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9355 OPAL AVE
MENTONE CA
92359-9605
US

IV. Provider business mailing address

9355 OPAL AVE
MENTONE CA
92359-9605
US

V. Phone/Fax

Practice location:
  • Phone: 909-705-5998
  • Fax: 909-389-9431
Mailing address:
  • Phone: 909-705-5998
  • Fax: 909-389-9431

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: