Provider Demographics
NPI:1831260629
Name:CRAWFORD, MICHIEL WAYNE (LCSW)
Entity type:Individual
Prefix:
First Name:MICHIEL
Middle Name:WAYNE
Last Name:CRAWFORD
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:809 COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33801-5508
Mailing Address - Country:US
Mailing Address - Phone:863-640-5474
Mailing Address - Fax:
Practice Address - Street 1:215 E BAY ST STE 2
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33801-4983
Practice Address - Country:US
Practice Address - Phone:863-640-5474
Practice Address - Fax:863-683-5196
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW00025811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ4650Medicare ID - Type Unspecified