Provider Demographics
NPI:1467874990
Name:MICKEY CROTHERS, PH.D., LLC
Entity Type:Organization
Organization Name:MICKEY CROTHERS, PH.D., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIE K.
Authorized Official - Middle Name:(MICKEY)
Authorized Official - Last Name:CROTHERS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:715-830-1400
Mailing Address - Street 1:4330 GOLF TER
Mailing Address - Street 2:SUITE 213-M
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-4683
Mailing Address - Country:US
Mailing Address - Phone:715-830-1400
Mailing Address - Fax:
Practice Address - Street 1:4330 GOLF TER
Practice Address - Street 2:SUITE 213-M
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-4683
Practice Address - Country:US
Practice Address - Phone:715-830-1400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-17
Last Update Date:2014-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty