Provider Demographics
NPI:1053443663
Name:CROUSE, STEPHANIE RENEE (LMP)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:RENEE
Last Name:CROUSE
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 SE CHKALOV DR
Mailing Address - Street 2:SUITE 7
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-5279
Mailing Address - Country:US
Mailing Address - Phone:360-885-1767
Mailing Address - Fax:360-885-1394
Practice Address - Street 1:615 SE CHKALOV DR
Practice Address - Street 2:SUITE 7
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-5279
Practice Address - Country:US
Practice Address - Phone:360-885-1767
Practice Address - Fax:360-885-1394
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00020903171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor