Provider Demographics
NPI:1417004458
Name:CRONK, EDITH LYNN (LCSW)
Entity type:Individual
Prefix:MS
First Name:EDITH
Middle Name:LYNN
Last Name:CRONK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1792
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-0424
Mailing Address - Country:US
Mailing Address - Phone:541-679-5334
Mailing Address - Fax:541-679-5334
Practice Address - Street 1:3856 CARNES RD
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-4521
Practice Address - Country:US
Practice Address - Phone:541-679-5334
Practice Address - Fax:541-679-5334
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL28871041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
119056Medicare ID - Type Unspecified