MEDICARE: STEPHANIE CROCKROM

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	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1669894168
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHANIE CROCKROM

Provider Business Mailing Address
First Line	:	3716 WARMBREEZE WAY
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89129-6845
Country	:	US
Telephone Number	:	702-813-6748
Fax Number	:

Provider Business Practice Location Address
First Line	:	3716 WARMBREEZE WAY
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89129-6845
Country	:	US
Telephone Number	:	702-813-6748
Fax Number	:

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

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

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Directions to “ STEPHANIE CROCKROM ” Practice Location

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