1720142193 NPI number — GWENDOLYN FRANCES CRAWFORD P.T.

Table of content: GWENDOLYN FRANCES CRAWFORD P.T. (NPI 1720142193)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720142193 NPI number — GWENDOLYN FRANCES CRAWFORD P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CRAWFORD
Provider First Name:
GWENDOLYN
Provider Middle Name:
FRANCES
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
P.T.
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:
1720142193
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/03/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 950248
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40295-0248
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-489-5730
Provider Business Mailing Address Fax Number:
502-489-5733

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11630 COMMONWEALTH DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40299-2300
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-267-6292
Provider Business Practice Location Address Fax Number:
502-267-6428
Provider Enumeration Date:
12/20/2006

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: 225100000X , with the licence number:  2151 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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