MEDICARE: MR. VICTOR LAMONT CROUCH LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker		GA

General Provider Information

NPI Number	:	1114181211
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. VICTOR LAMONT CROUCH LCSW

Provider Business Mailing Address
First Line	:	3700 BRIDGEWATER RD
Second Line	:	SUITE G-2
City	:	COLUMBUS
State	:	GA
Zip	:	31909-4767
Country	:	US
Telephone Number	:	404-229-7933
Fax Number	:

Provider Business Practice Location Address
First Line	:	3100 GENTIAN BOULEVARD
Second Line	:	SUITE 007L
City	:	COLUMBUS
State	:	GA
Zip	:	31907-8200
Country	:	US
Telephone Number	:	404-229-7933
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/17/2008
Last Update Date	:	11/24/2008

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