Provider Demographics
NPI:1417188368
Name:CROWE, GARY W (ADMINISTRATOR)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:W
Last Name:CROWE
Suffix:
Gender:M
Credentials:ADMINISTRATOR
Other - Prefix:MRS
Other - First Name:DARLENE
Other - Middle Name:G
Other - Last Name:CROWE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CO-OWNER
Mailing Address - Street 1:604 LEIGHTON RD
Mailing Address - Street 2:CROWES RESIDENTIAL CARE
Mailing Address - City:AUGUSTA
Mailing Address - State:ME
Mailing Address - Zip Code:04330
Mailing Address - Country:US
Mailing Address - Phone:207-623-5355
Mailing Address - Fax:
Practice Address - Street 1:604 LEIGHTON RD
Practice Address - Street 2:CROWES RESIDENTIAL CARE
Practice Address - City:AUGUSTA
Practice Address - State:ME
Practice Address - Zip Code:04330
Practice Address - Country:US
Practice Address - Phone:207-623-5355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-27
Last Update Date:2009-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEALLS2661320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME131330000Medicaid