MEDICARE: MS. LORRAINE CROCKFORD MFT

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	106H00000X	Marriage & Family Therapist	41539	CA

General Provider Information

NPI Number	:	1629132188
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LORRAINE CROCKFORD MFT

Provider Business Mailing Address
First Line	:	2261 ELM ST
Second Line	:
City	:	NAPA
State	:	CA
Zip	:	94559-3721
Country	:	US
Telephone Number	:	707-259-8169
Fax Number	:	707-259-8651

Provider Business Practice Location Address
First Line	:	2261 ELM ST
Second Line	:
City	:	NAPA
State	:	CA
Zip	:	94559-3721
Country	:	US
Telephone Number	:	707-259-8169
Fax Number	:	707-259-8651

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

Provider Enumeration Date	:	12/20/2006
Last Update Date	:	07/08/2007

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