Provider Demographics
NPI:1467887372
Name:CROTHERS, CASEY LYNN (COTA)
Entity Type:Individual
Prefix:MS
First Name:CASEY
Middle Name:LYNN
Last Name:CROTHERS
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5155 N 74TH DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85303-6132
Mailing Address - Country:US
Mailing Address - Phone:401-439-8683
Mailing Address - Fax:
Practice Address - Street 1:5155 N 74TH DR
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85303-6132
Practice Address - Country:US
Practice Address - Phone:401-439-8683
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-10
Last Update Date:2013-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5550172V00000X
MAOTA00058172V00000X
MA1541172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker