Provider Demographics
NPI:1558562488
Name:CROCOMBE, LARRY KEITH (BACACII)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:KEITH
Last Name:CROCOMBE
Suffix:
Gender:M
Credentials:BACACII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2561 ELMWOOD LN
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81005-2703
Mailing Address - Country:US
Mailing Address - Phone:719-564-4847
Mailing Address - Fax:
Practice Address - Street 1:509 E 13TH ST
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81001-2940
Practice Address - Country:US
Practice Address - Phone:719-546-6666
Practice Address - Fax:719-543-7764
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO4136101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)