Provider Demographics
NPI:1790169324
Name:CRUTCHFIELD, LAKETA
Entity Type:Individual
Prefix:
First Name:LAKETA
Middle Name:
Last Name:CRUTCHFIELD
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 1:17850 HOLLAND RD
Mailing Address - Street 2:
Mailing Address - City:BROOKPARK
Mailing Address - State:OH
Mailing Address - Zip Code:44142-3526
Mailing Address - Country:US
Mailing Address - Phone:440-454-3918
Mailing Address - Fax:
Practice Address - Street 1:6753 STATE RD
Practice Address - Street 2:
Practice Address - City:PARMA
Practice Address - State:OH
Practice Address - Zip Code:44134-4517
Practice Address - Country:US
Practice Address - Phone:216-645-5017
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-14
Last Update Date:2015-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1451411104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker