Healthcare Provider Details

I. General information

NPI: 1164890877
Provider Name (Legal Business Name): MARCIE NICOLE CRAIN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2015
Last Update Date: 11/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 REYNOLDS RD
GLASGOW KY
42141-1177
US

IV. Provider business mailing address

104 REYNOLDS RD
GLASGOW KY
42141-1177
US

V. Phone/Fax

Practice location:
  • Phone: 270-678-4801
  • Fax: 270-678-3866
Mailing address:
  • Phone: 270-678-4801
  • Fax: 270-678-3866

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number7303
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number7303
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number253029
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: