Healthcare Provider Details

I. General information

NPI: 1811071046
Provider Name (Legal Business Name): MALISSA K CROWE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 SAGAMORE PKWY W
WEST LAFAYETTE BRA IN
47906-1569
US

IV. Provider business mailing address

1351 S SHARON CHAPEL RD
WEST LAFAYETTE BRA IN
47906-4342
US

V. Phone/Fax

Practice location:
  • Phone: 765-491-6175
  • Fax: 765-743-5850
Mailing address:
  • Phone: 765-491-6175
  • Fax: 765-743-5850

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number34005071A
License Number StateIN

VIII. Authorized Official

Name: MALISSA K CROWE
Title or Position: SOLE PROPRIETOR
Credential: LCSW
Phone: 765-491-6175