Provider Demographics
NPI:1407930944
Name:CROUCH, MARVIN ORA (LIMHP, LADC)
Entity Type:Individual
Prefix:MR
First Name:MARVIN
Middle Name:ORA
Last Name:CROUCH
Suffix:
Gender:M
Credentials:LIMHP, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7450 W 29TH ST
Mailing Address - Street 2:
Mailing Address - City:KEARNEY
Mailing Address - State:NE
Mailing Address - Zip Code:68845-8808
Mailing Address - Country:US
Mailing Address - Phone:308-234-1148
Mailing Address - Fax:
Practice Address - Street 1:2811 30TH AVE
Practice Address - Street 2:
Practice Address - City:KEARNEY
Practice Address - State:NE
Practice Address - Zip Code:68845-4036
Practice Address - Country:US
Practice Address - Phone:308-237-6865
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2014-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE296101YA0400X
NE35101YM0800X
NE621101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE100025152000Medicaid
NE100025152100Medicaid