Provider Demographics
NPI:1174034995
Name:CROCKRON, DAVID L (LSW, CDCA)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:L
Last Name:CROCKRON
Suffix:
Gender:M
Credentials:LSW, CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3110 ARBORSYE CT
Mailing Address - Street 2:
Mailing Address - City:REYNOLDSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43068-9102
Mailing Address - Country:US
Mailing Address - Phone:614-286-9510
Mailing Address - Fax:
Practice Address - Street 1:16 W LONG ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-2815
Practice Address - Country:US
Practice Address - Phone:614-225-0990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-19
Last Update Date:2017-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH080474101YA0400X
OHS13029641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)