Provider Demographics
NPI:1578074308
Name:CROCKFORD, COLLEEN (MSW, LICSW)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:CROCKFORD
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13572 PARTRIDGE CIR NW
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MN
Mailing Address - Zip Code:55304-4290
Mailing Address - Country:US
Mailing Address - Phone:612-251-6741
Mailing Address - Fax:
Practice Address - Street 1:8421 WAYZATA BLVD
Practice Address - Street 2:
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55426-1352
Practice Address - Country:US
Practice Address - Phone:651-714-3848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-19
Last Update Date:2017-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN204961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical