Provider Demographics
NPI:1508811464
Name:CROTINGER, TERRY DIANE (LPC)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:DIANE
Last Name:CROTINGER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:TERRY
Other - Middle Name:D
Other - Last Name:CROTINGER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPCC
Mailing Address - Street 1:PO BOX 1396
Mailing Address - Street 2:
Mailing Address - City:RATON
Mailing Address - State:NM
Mailing Address - Zip Code:87740-1396
Mailing Address - Country:US
Mailing Address - Phone:575-707-2257
Mailing Address - Fax:888-972-3649
Practice Address - Street 1:250 PARK AVENUE
Practice Address - Street 2:
Practice Address - City:RATON
Practice Address - State:NM
Practice Address - Zip Code:87740
Practice Address - Country:US
Practice Address - Phone:575-707-2257
Practice Address - Fax:888-972-3649
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-22
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC1658101YP2500X
NMLPCC 0159381101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ002479OtherAHCCCS