Provider Demographics
NPI:1821584293
Name:CROLEY, CHRISTOPHER SHANE (MFTA)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:SHANE
Last Name:CROLEY
Suffix:
Gender:M
Credentials:MFTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10103 CARDIGAN DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40299-2805
Mailing Address - Country:US
Mailing Address - Phone:859-321-5879
Mailing Address - Fax:
Practice Address - Street 1:1169 EASTERN PKWY STE 3364
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40217-1415
Practice Address - Country:US
Practice Address - Phone:502-381-9996
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-09
Last Update Date:2018-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY173673106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist