Provider Demographics
NPI:1124477427
Name:CROUCH, MALLORY JEAN (LCSW, LAC)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:JEAN
Last Name:CROUCH
Suffix:
Gender:F
Credentials:LCSW, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3720 REVERE ST
Mailing Address - Street 2:STE. B
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80239
Mailing Address - Country:US
Mailing Address - Phone:720-503-2405
Mailing Address - Fax:
Practice Address - Street 1:3720 REVERE ST.
Practice Address - Street 2:STE. B
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80239
Practice Address - Country:US
Practice Address - Phone:720-503-2405
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-07
Last Update Date:2019-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0000701101YA0400X
CO099236711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)