Provider Demographics
NPI:1003825142
Name:CROWDER, CONNIE PHILLIPS (LCSW)
Entity Type:Individual
Prefix:MS
First Name:CONNIE
Middle Name:PHILLIPS
Last Name:CROWDER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:565 MILWAUKEE AVE
Mailing Address - Street 2:SUITE 3C
Mailing Address - City:BURLINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53105-1254
Mailing Address - Country:US
Mailing Address - Phone:262-757-0016
Mailing Address - Fax:262-757-0018
Practice Address - Street 1:565 MILWAUKEE AVE
Practice Address - Street 2:SUITE 3C
Practice Address - City:BURLINGTON
Practice Address - State:WI
Practice Address - Zip Code:53105-1254
Practice Address - Country:US
Practice Address - Phone:262-757-0016
Practice Address - Fax:262-757-0018
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2010-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2629-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39189100Medicaid
WI39189100Medicaid