Healthcare Provider Details

I. General information

NPI: 1912467416
Provider Name (Legal Business Name): EMILY CRISP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2019
Last Update Date: 12/09/2024
Certification Date: 12/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

619 N 30TH ST
PADUCAH KY
42001-4047
US

IV. Provider business mailing address

PO BOX 931142
ATLANTA GA
31193-1142
US

V. Phone/Fax

Practice location:
  • Phone: 270-444-7898
  • Fax: 270-933-1786
Mailing address:
  • Phone: 615-247-5487
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-24-76666
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number0-24-15285
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-19-77799
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: