MEDICARE: MS. THERESA D CROTTY 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	LSW0000004741	TN
2	1041C0700X	Clinical Social Worker		IL

General Provider Information

NPI Number	:	1255402368
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. THERESA D CROTTY LCSW

Provider Business Mailing Address
First Line	:	1263 HARBIN HILL RD
Second Line	:
City	:	MOUNTAIN CITY
State	:	TN
Zip	:	37683-6089
Country	:	US
Telephone Number	:	630-373-5536
Fax Number	:

Provider Business Practice Location Address
First Line	:	1263 HARBIN HILL RD
Second Line	:
City	:	MOUNTAIN CITY
State	:	TN
Zip	:	37683-6089
Country	:	US
Telephone Number	:	423-373-5536
Fax Number	:

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

Provider Enumeration Date	:	11/11/2006
Last Update Date	:	01/09/2008

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