Healthcare Provider Details

I. General information

NPI: 1164544631
Provider Name (Legal Business Name): CHRISTOPHER HOWARD CROMWELL BACHELORS OF ARTS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 LAKE TAHOE BLVD
SOUTH LAKE TAHOE CA
96150-6305
US

IV. Provider business mailing address

2031 NEZ PERCE DR
SOUTH LAKE TAHOE CA
96150-5358
US

V. Phone/Fax

Practice location:
  • Phone: 530-573-3251
  • Fax:
Mailing address:
  • Phone: 530-573-0315
  • Fax: 530-573-0315

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: