=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205326816
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CROCUS COUNSELING, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/18/2018
-----------------------------------------------------
Last Update Date | 02/03/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 32 N WASHINGTON ST STE 3
-----------------------------------------------------
City | YPSILANTI
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48197-2662
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-508-2806
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 32 N WASHINGTON ST STE 3
-----------------------------------------------------
City | YPSILANTI
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48197-2662
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-508-2806
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | CARA A TALASKA
-----------------------------------------------------
Credential | LPC, NCC
-----------------------------------------------------
Telephone | 734-508-2806
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number | 6401010650
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------