Provider Demographics
NPI:1316118326
Name:MATTHEW J. CROUCH, MD, PLLC
Entity type:Organization
Organization Name:MATTHEW J. CROUCH, MD, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LAVONNA
Authorized Official - Middle Name:M
Authorized Official - Last Name:LATTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:4794-442-5437
Mailing Address - Street 1:1 W SUNBRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-1825
Mailing Address - Country:US
Mailing Address - Phone:479-442-5437
Mailing Address - Fax:479-521-5996
Practice Address - Street 1:1 W SUNBRIDGE DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-1825
Practice Address - Country:US
Practice Address - Phone:479-442-5437
Practice Address - Fax:479-521-5996
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-18
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE47592084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Single Specialty