Healthcare Provider Details

I. General information

NPI: 1447511605
Provider Name (Legal Business Name): KEITH L CROWNOVER PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2012
Last Update Date: 11/10/2025
Certification Date: 11/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3205 TAHITI ST NE
ALBUQUERQUE NM
87111-5342
US

IV. Provider business mailing address

3205 TAHITI ST NE
ALBUQUERQUE NM
87111-5342
US

V. Phone/Fax

Practice location:
  • Phone: 405-824-9625
  • Fax:
Mailing address:
  • Phone: 405-824-9625
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC0017517
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC6141
License Number StateOK
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCCMH0219991
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: