Basic Information
| Provider Information | |||||||||
| NPI: | 1780631747 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CROWNOVER | ||||||||
| FirstName: | CARRIE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5500 E KELLOGG DR | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672181607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166513621 | ||||||||
| FaxNumber: | 3166343091 | ||||||||
| Practice Location | |||||||||
| Address1: | 5500 E KELLOGG DR | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672181607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166513621 | ||||||||
| FaxNumber: | 3166343091 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2006 | ||||||||
| LastUpdateDate: | 11/06/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC1900X | 1759 | KS | Y | Behavioral Health & Social Service Providers | Psychologist | Counseling |
ID Information
| ID | Type | State | Issuer | Description | 10097960A | 05 | KS | MEDICAID | 201736 | 01 | KS | BLUE CROSS | OTHER |