Provider Demographics
NPI:1073565925
Name:CRAWFORD, TIMOTHY WAYNE (PHD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:WAYNE
Last Name:CRAWFORD
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 NORTHGATE PARK DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27106-3482
Mailing Address - Country:US
Mailing Address - Phone:336-499-3622
Mailing Address - Fax:336-499-3624
Practice Address - Street 1:300 NORTHGATE PARK DR
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-3482
Practice Address - Country:US
Practice Address - Phone:336-499-3622
Practice Address - Fax:336-499-3624
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1576103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6000609Medicaid