Provider Demographics
NPI:1225791353
Name:CRENSHAW, AMARGO SHANDALE
Entity Type:Individual
Prefix:
First Name:AMARGO
Middle Name:SHANDALE
Last Name:CRENSHAW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:535 WOODRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-3633
Mailing Address - Country:US
Mailing Address - Phone:404-661-3920
Mailing Address - Fax:
Practice Address - Street 1:535 WOODRIDGE DR
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30339-3633
Practice Address - Country:US
Practice Address - Phone:404-661-3920
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-15
Last Update Date:2021-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA010389101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional