=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013054345
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DONALD ALDEN CRONK III M.S., LMHC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/30/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 616 E COLFAX AVE
-----------------------------------------------------
City | SOUTH BEND
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46617-2827
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 574-277-7734
-----------------------------------------------------
Fax | 574-277-7734
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 616 E COLFAX AVE
-----------------------------------------------------
City | SOUTH BEND
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46617-2827
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 574-277-7734
-----------------------------------------------------
Fax | 574-277-7734
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 39000750A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------