=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538607155
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DONALD P CRUMM LADC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/02/2017
-----------------------------------------------------
Last Update Date | 07/29/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3500 LAKESIDE CT STE 204
-----------------------------------------------------
City | RENO
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89509-4896
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 775-349-2497
-----------------------------------------------------
Fax | 775-243-2567
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3500 LAKESIDE CT STE 204
-----------------------------------------------------
City | RENO
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89509-4896
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 775-349-2497
-----------------------------------------------------
Fax | 775-243-2567
-----------------------------------------------------
=====================================================
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 | 01870-L
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------