Basic Information
| Provider Information | |||||||||
| NPI: | 1912916065 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CROWDER | ||||||||
| FirstName: | DONAL | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1168 E CUTLAR XING | ||||||||
| Address2: | |||||||||
| City: | LELAND | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284516484 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9103323800 | ||||||||
| FaxNumber: | 9102510421 | ||||||||
| Practice Location | |||||||||
| Address1: | 1168 E CUTLAR XING | ||||||||
| Address2: | |||||||||
| City: | LELAND | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284516484 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9103323800 | ||||||||
| FaxNumber: | 9102510421 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2006 | ||||||||
| LastUpdateDate: | 09/15/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 934-057 | WI | N | Behavioral Health & Social Service Providers | Psychologist | 103T00000X | 5414 | NC | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 39029800 | 05 | WI | MEDICAID |