Basic Information
| Provider Information | |||||||||
| NPI: | 1336204593 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CROWE | ||||||||
| FirstName: | CONNIE | ||||||||
| MiddleName: | |||||||||
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| Credential: | LMFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 175 EMERY HWY | ||||||||
| Address2: | |||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312173692 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4787514444 | ||||||||
| FaxNumber: | 4787514446 | ||||||||
| Practice Location | |||||||||
| Address1: | 175 EMERY HWY | ||||||||
| Address2: | |||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312173692 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4787514444 | ||||||||
| FaxNumber: | 4787514446 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | MFT001019 | GA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | MFT001019 | 01 | GA | LMFT LICENSE | OTHER |