Provider Demographics
NPI:1477955144
Name:CROMPTON, MARY KATHARINE (LAC, LCSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KATHARINE
Last Name:CROMPTON
Suffix:
Gender:F
Credentials:LAC, LCSW
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:KATHARINE
Other - Last Name:CROMPTON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LICSW LAC
Mailing Address - Street 1:891 BELSLY BLVD
Mailing Address - Street 2:
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56560-5055
Mailing Address - Country:US
Mailing Address - Phone:218-287-4338
Mailing Address - Fax:218-287-5928
Practice Address - Street 1:1126 WESTRAC DR S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-2473
Practice Address - Country:US
Practice Address - Phone:218-287-4338
Practice Address - Fax:218-287-5928
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-24
Last Update Date:2017-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND40041041C0700X
ND1643101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NDI20161021001033Medicare PIN