Provider Demographics
NPI:1740587559
Name:MCCROVITZ, ANTHONY M (PHD)
Entity Type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:M
Last Name:MCCROVITZ
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1880 CATKIN CIRCLE
Mailing Address - Street 2:
Mailing Address - City:CHESTERTON
Mailing Address - State:IN
Mailing Address - Zip Code:46304
Mailing Address - Country:US
Mailing Address - Phone:219-771-2940
Mailing Address - Fax:219-921-0143
Practice Address - Street 1:621 BROADWAY
Practice Address - Street 2:
Practice Address - City:CHESTERTON
Practice Address - State:IN
Practice Address - Zip Code:46304-2259
Practice Address - Country:US
Practice Address - Phone:219-921-5492
Practice Address - Fax:219-921-0143
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-15
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39002197A101YM0800X
IN20043441A103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100110700Medicaid