Provider Demographics
NPI:1760143614
Name:LACRUE, ANDREW
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:LACRUE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9469 E 109TH AVE
Mailing Address - Street 2:
Mailing Address - City:COMMERCE CITY
Mailing Address - State:CO
Mailing Address - Zip Code:80640-7551
Mailing Address - Country:US
Mailing Address - Phone:720-999-4268
Mailing Address - Fax:
Practice Address - Street 1:10190 BANNOCK ST
Practice Address - Street 2:
Practice Address - City:NORTHGLENN
Practice Address - State:CO
Practice Address - Zip Code:80260-6083
Practice Address - Country:US
Practice Address - Phone:303-237-6865
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-03
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty