Healthcare Provider Details

I. General information

NPI: 1043552524
Provider Name (Legal Business Name): TORI CROSHAW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2013
Last Update Date: 09/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

372 S EAGLE RD STE 190
EAGLE ID
83616
US

IV. Provider business mailing address

372 S EAGLE RD STE 190
EAGLE ID
83616-5908
US

V. Phone/Fax

Practice location:
  • Phone: 303-330-3694
  • Fax:
Mailing address:
  • Phone: 303-330-3694
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLMSW-38021
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: