Provider Demographics
NPI:1487179776
Name:CROTWELL, SHIRLEY MAE (PHD)
Entity Type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:MAE
Last Name:CROTWELL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2529 TREVISO DR SE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-8944
Mailing Address - Country:US
Mailing Address - Phone:505-306-9254
Mailing Address - Fax:
Practice Address - Street 1:1005 21ST ST SE STE 18
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-4030
Practice Address - Country:US
Practice Address - Phone:505-225-2033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-07
Last Update Date:2022-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPSY1480103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical