Basic Information
| Provider Information | |||||||||
| NPI: | 1760984694 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CROTTY | ||||||||
| FirstName: | MAYRA | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | LISW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1160 W BROAD ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432221352 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142741455 | ||||||||
| FaxNumber: | 6142741433 | ||||||||
| Practice Location | |||||||||
| Address1: | 1160 W BROAD ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432221352 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142741455 | ||||||||
| FaxNumber: | 6142741433 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2018 | ||||||||
| LastUpdateDate: | 07/07/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | S.1700241-TRNE | OH | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 104100000X | I.2203712 | OH | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 0271444 | 05 | OH | MEDICAID |