Provider Demographics
NPI:1619452943
Name:CROUCH, SAMUEL WILLIAM (PLADC)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:WILLIAM
Last Name:CROUCH
Suffix:
Gender:M
Credentials:PLADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:921 W 36TH ST
Mailing Address - Street 2:
Mailing Address - City:SCOTTSBLUFF
Mailing Address - State:NE
Mailing Address - Zip Code:69361-5009
Mailing Address - Country:US
Mailing Address - Phone:308-225-0500
Mailing Address - Fax:
Practice Address - Street 1:921 W 36TH ST
Practice Address - Street 2:
Practice Address - City:SCOTTSBLUFF
Practice Address - State:NE
Practice Address - Zip Code:69361-5009
Practice Address - Country:US
Practice Address - Phone:308-225-0500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-02
Last Update Date:2019-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NEP-1628101YA0400X
NE11806101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10026769300Medicaid