Provider Demographics
NPI:1952895773
Name:CROAKE, DANIEL JACOB (PHD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:JACOB
Last Name:CROAKE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1222 S PATTERSON BLVD
Mailing Address - Street 2:STE 400
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45402-2642
Mailing Address - Country:US
Mailing Address - Phone:937-496-2620
Mailing Address - Fax:937-424-8518
Practice Address - Street 1:740 S LIMESTONE
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40536-0001
Practice Address - Country:US
Practice Address - Phone:859-218-0526
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-15
Last Update Date:2019-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY140620235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist