Provider Demographics
NPI:1194173211
Name:CROTWELL, TARA NICOLE (MS)
Entity type:Individual
Prefix:MRS
First Name:TARA
Middle Name:NICOLE
Last Name:CROTWELL
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1016 TOWLE CIR
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32514-1925
Mailing Address - Country:US
Mailing Address - Phone:205-335-7755
Mailing Address - Fax:
Practice Address - Street 1:1108 AIRPORT BLVD STE A
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-8623
Practice Address - Country:US
Practice Address - Phone:850-471-1005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-31
Last Update Date:2016-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSZ 7553235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist