Provider Demographics
NPI:1326198094
Name:ALDRED-CROUCH, MARY ROGERS (MSW, MPH, LICSW, MAC)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ROGERS
Last Name:ALDRED-CROUCH
Suffix:
Gender:F
Credentials:MSW, MPH, LICSW, MAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 2, BOX 753
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:WV
Mailing Address - Zip Code:25541-9506
Mailing Address - Country:US
Mailing Address - Phone:304-972-4911
Mailing Address - Fax:866-651-5220
Practice Address - Street 1:RR 2, BOX 753
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:WV
Practice Address - Zip Code:25541-9506
Practice Address - Country:US
Practice Address - Phone:304-972-4911
Practice Address - Fax:866-651-5220
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVDP009422001041C0700X
510829101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVQ45603GOtherMEDICARE
WVQ45603DMedicare PIN
WVQ45603CMedicare PIN
WVQ45603BMedicare PIN
WV2028491Medicare PIN
WVQ45603EMedicare PIN
WV3810003251Medicaid