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General NPI Number Information
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NPI Number | 1811289549
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Entity Type | Individual
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Provider Name | DERRICK ALIF CROWLEY
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Gender | Male
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Dates
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Enumeration Date | 05/13/2011
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Last Update Date | 06/03/2014
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Provider Practice Location Address
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Address Line | 17 MAIN ST
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City | CORTLAND
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State | NY
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Zip | 13045-6606
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Country | US
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Telephone | 315-440-6611
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Fax |
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Provider Business Mailing Address
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Address Line | 17 MAIN ST
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City | SYRACUSE
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State | NY
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Zip | 13209-1810
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 25195
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License Number State | NY
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