Provider Demographics
NPI:1790424745
Name:CROTWELL, LARA DANIELLE (MS, CF-SLP)
Entity type:Individual
Prefix:MISS
First Name:LARA
Middle Name:DANIELLE
Last Name:CROTWELL
Suffix:
Gender:F
Credentials:MS, CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1819 38TH AVE
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94122-4147
Mailing Address - Country:US
Mailing Address - Phone:415-404-0497
Mailing Address - Fax:
Practice Address - Street 1:2000 VAN NESS AVE
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94109-3023
Practice Address - Country:US
Practice Address - Phone:415-563-6541
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-28
Last Update Date:2022-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA000000235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAR03701345Medicaid