1649694662 NPI number — KELLY L CRENSHAW PSYD

Table of content: KELLY L CRENSHAW PSYD (NPI 1649694662)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649694662 NPI number — KELLY L CRENSHAW PSYD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CRENSHAW
Provider First Name:
KELLY
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PSYD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1649694662
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12 BELLWETHER WAY STE 240
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELLINGHAM
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98225-2959
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-588-2500
Provider Business Mailing Address Fax Number:
360-785-2016

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12 BELLWETHER WAY STE 240
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BELLINGHAM
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98225-2959
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-588-2500
Provider Business Practice Location Address Fax Number:
360-785-2016
Provider Enumeration Date:
02/11/2014

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103G00000X , with the licence number:  PY60885078 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 103TA0700X , with the licence number: PY60885078 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TA0700X , with the licence number: 36685 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TB0200X , with the licence number: PY60885078 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TB0200X , with the licence number: 36685 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TC0700X , with the licence number: PY60885078 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TC0700X , with the licence number: 36685 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)