Healthcare Provider Details

I. General information

NPI: 1861410888
Provider Name (Legal Business Name): MARY CHRISTINE CRENSHAW PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: TINA CRENSHAW PH.D.

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 06/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 BEAVER MEADOW RD
NORWICH VT
05055-9305
US

IV. Provider business mailing address

PO BOX 162
THETFORD CENTER VT
05075-0162
US

V. Phone/Fax

Practice location:
  • Phone: 802-649-2260
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number71955
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: