MEDICARE: AMARGO SHANDALE CRENSHAW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	010389	GA

General Provider Information

NPI Number	:	1225791353
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMARGO SHANDALE CRENSHAW

Provider Business Mailing Address
First Line	:	535 WOODRIDGE DR
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30339-3633
Country	:	US
Telephone Number	:	404-661-3920
Fax Number	:

Provider Business Practice Location Address
First Line	:	535 WOODRIDGE DR
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30339-3633
Country	:	US
Telephone Number	:	404-661-3920
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/15/2021
Last Update Date	:	10/15/2021

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Directions to “ AMARGO SHANDALE CRENSHAW ” Practice Location

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