Provider Demographics
NPI:1780836783
Name:CROWE, WANDA LYNN
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:LYNN
Last Name:CROWE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 28TH ST S STE C
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-8745
Mailing Address - Country:US
Mailing Address - Phone:701-404-1100
Mailing Address - Fax:701-540-6498
Practice Address - Street 1:901 28TH ST S STE C
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-8745
Practice Address - Country:US
Practice Address - Phone:701-404-1100
Practice Address - Fax:701-540-6498
Is Sole Proprietor?:No
Enumeration Date:2008-10-21
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN303561101YA0400X
171M00000X
ND1651101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator