=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043271182
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DOUGLAS CRUSH PH.D
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/29/2006
-----------------------------------------------------
Last Update Date | 03/12/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1934 NILES CORTLAND RD NE STE B
-----------------------------------------------------
City | WARREN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44484-1055
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-841-4032
-----------------------------------------------------
Fax | 330-841-4381
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2980 BELMONT AVE
-----------------------------------------------------
City | YOUNGSTOWN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44505-1834
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-759-2310
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 2309
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------