Provider Demographics
NPI:1396008868
Name:CROWELL, DESIRAE ANNE
Entity Type:Individual
Prefix:MRS
First Name:DESIRAE
Middle Name:ANNE
Last Name:CROWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DESIRAE
Other - Middle Name:ANNE
Other - Last Name:CELIBERTI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1219 DUNN AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-2405
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1219 DUNN AVE
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-2405
Practice Address - Country:US
Practice Address - Phone:386-931-6227
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-20
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY607155121174400000X
NY1-16-21492103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No174400000XOther Service ProvidersSpecialist