Provider Demographics
NPI:1902959547
Name:CROUCH, PAMELA LYNNE
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:LYNNE
Last Name:CROUCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:PAMELA
Other - Middle Name:LYNNE
Other - Last Name:CHAPPELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4903 S CALLE ENCINA
Mailing Address - Street 2:
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85650-8903
Mailing Address - Country:US
Mailing Address - Phone:520-559-4850
Mailing Address - Fax:
Practice Address - Street 1:3555 E FRY BLVD
Practice Address - Street 2:
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-2972
Practice Address - Country:US
Practice Address - Phone:520-515-2790
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ598542Medicaid