Basic Information
| Provider Information | |||||||||
| NPI: | 1780031831 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CROCKFORD | ||||||||
| FirstName: | DANE | ||||||||
| MiddleName: | P | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PSYD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 823 GATEWAY CENTER WAY | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921024541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6195152300 | ||||||||
| FaxNumber: | 6192690674 | ||||||||
| Practice Location | |||||||||
| Address1: | 990 HIGHLAND DR | ||||||||
| Address2: | STE 110-P | ||||||||
| City: | SOLANA BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920752408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103089761 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2016 | ||||||||
| LastUpdateDate: | 01/10/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC2200X | PSY28313 | CA | N | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent | 103TF0000X | PSY28313 | CA | N | Behavioral Health & Social Service Providers | Psychologist | Family | 103TC0700X | PSY28313 | CA | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.