MEDICARE: MR. JAMES CRAWFORD ICS

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	14524-132	WI
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	15371-135	WI

General Provider Information

NPI Number	:	1700129376
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JAMES CRAWFORD ICS

Provider Business Mailing Address
First Line	:	1213 N SHERMAN AVE # 323
Second Line	:
City	:	MADISON
State	:	WI
Zip	:	53704-4236
Country	:	US
Telephone Number	:	608-445-4886
Fax Number	:	608-467-9135

Provider Business Practice Location Address
First Line	:	4222 MILWAUKEE ST STE 2
Second Line	:
City	:	MADISON
State	:	WI
Zip	:	53714-3534
Country	:	US
Telephone Number	:	608-467-9134
Fax Number	:	608-467-9135

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

Provider Enumeration Date	:	04/02/2013
Last Update Date	:	04/02/2013

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