Provider Demographics
NPI:1639913080
Name:CROUCH, CAMARYN GRAYCE IRENE
Entity type:Individual
Prefix:
First Name:CAMARYN
Middle Name:GRAYCE IRENE
Last Name:CROUCH
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 1:30144 GAY RD
Mailing Address - Street 2:
Mailing Address - City:LAKE LINDEN
Mailing Address - State:MI
Mailing Address - Zip Code:49945-9735
Mailing Address - Country:US
Mailing Address - Phone:906-370-0787
Mailing Address - Fax:
Practice Address - Street 1:30144 GAY RD
Practice Address - Street 2:
Practice Address - City:LAKE LINDEN
Practice Address - State:MI
Practice Address - Zip Code:49945-9735
Practice Address - Country:US
Practice Address - Phone:906-370-0787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-20
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician