MEDICARE: MICKEY CROTHERS, PH.D., LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	101YM0800X	Mental Health Counselor
2	103TC0700X	Clinical Psychologist
3	103T00000X	Psychologist

General Provider Information

NPI Number	:	1467874990
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MICKEY CROTHERS, PH.D., LLC

Provider Business Mailing Address
First Line	:	4330 GOLF TER
Second Line	:	SUITE 213-M
City	:	EAU CLAIRE
State	:	WI
Zip	:	54701-4683
Country	:	US
Telephone Number	:	715-830-1400
Fax Number	:

Provider Business Practice Location Address
First Line	:	4330 GOLF TER
Second Line	:	SUITE 213-M
City	:	EAU CLAIRE
State	:	WI
Zip	:	54701-4683
Country	:	US
Telephone Number	:	715-830-1400
Fax Number	:

Authorized Official
Title or Position	:	MEMBER
Name	:	DR. MARIE K. (MICKEY) CROTHERS
Credential	:	PH.D.
Telephone Number	:	715-830-1400

Provider Enumeration Date	:	01/17/2014
Last Update Date	:	02/18/2014

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