=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114122629
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LYNDA MAE CROW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/15/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3051 N VAN HORN RD
-----------------------------------------------------
City | FAIRBANKS
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99701-7319
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-451-1170
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 660 WILCOX AVE APT 18 P.O. BOX 74601
-----------------------------------------------------
City | FAIRBANKS
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99709-3649
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-451-1170
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 2074
-----------------------------------------------------
License Number State | AK
-----------------------------------------------------