Healthcare Provider Details

I. General information

NPI: 1588632749
Provider Name (Legal Business Name): TAMARA D CROWN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 06/10/2024
Certification Date: 05/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

517 TALONS REACH RUN
BERTHOUD CO
80513-8701
US

IV. Provider business mailing address

517 TALONS REACH RUN
BERTHOUD CO
80513-8701
US

V. Phone/Fax

Practice location:
  • Phone: 405-630-0189
  • Fax:
Mailing address:
  • Phone: 405-630-0189
  • Fax: 405-840-3794

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1595
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: