Healthcare Provider Details

I. General information

NPI: 1770113094
Provider Name (Legal Business Name): CORAL K CROUCH OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/26/2020
Last Update Date: 01/26/2020
Certification Date: 01/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1205B W GREEN OAKS BLVD
ARLINGTON TX
76013-8301
US

IV. Provider business mailing address

2001 ADEN RD APT 55
FORT WORTH TX
76116-1930
US

V. Phone/Fax

Practice location:
  • Phone: 817-457-3088
  • Fax:
Mailing address:
  • Phone: 210-846-9315
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License Number120551
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code225XF0002X
TaxonomyFeeding, Eating & Swallowing Occupational Therapist
License Number120551
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number120551
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: