Healthcare Provider Details

I. General information

NPI: 1033125059
Provider Name (Legal Business Name): PAUL SAMUEL CRENSHAW LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 12/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

726 14TH ST STE A
MODESTO CA
95354-2549
US

IV. Provider business mailing address

2113 ALOHA WAY
MODESTO CA
95350-3103
US

V. Phone/Fax

Practice location:
  • Phone: 209-614-1440
  • Fax:
Mailing address:
  • Phone: 209-614-1440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS 17708
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: