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NPI Code Detail

MEDICARE: CARL CROCKHAM

MEDICARE: CARL CROCKHAM
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
11041C0700XClinical Social Worker

General Provider Information

NPI Number : 1174938518
Entity Type Code : Individual
Provider Name (Legal Business Name) : CARL CROCKHAM
Provider Business Mailing Address
First Line : 4325 W ROME BLVD APT 1184
Second Line :
City : NORTH LAS VEGAS
State : NV
Zip : 89084-5409
Country : US
Telephone Number : 702-561-0866
Fax Number :
Provider Business Practice Location Address
First Line : 4325 W ROME BLVD APT 1184
Second Line :
City : NORTH LAS VEGAS
State : NV
Zip : 89084-5409
Country : US
Telephone Number : 702-561-0866
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/24/2014
Last Update Date : 06/24/2014

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Directions to “ CARL CROCKHAM ” Practice Location

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