Provider Demographics
NPI:1982416491
Name:CROOM, MICHAEL DUSHAUN
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DUSHAUN
Last Name:CROOM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:930 S MOUNT VERNON AVE STE 90
Mailing Address - Street 2:
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-3928
Mailing Address - Country:US
Mailing Address - Phone:909-660-0097
Mailing Address - Fax:
Practice Address - Street 1:MANUEL A. SALINAS ELEMENTARY SCHOOL
Practice Address - Street 2:2699 N. CALIFORNIA ST
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92407
Practice Address - Country:US
Practice Address - Phone:909-880-6600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-22
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty