Provider Demographics
NPI:1316542194
Name:CREWS, CHERYL R
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:R
Last Name:CREWS
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 1:1505 GRIMES AVE
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:OH
Mailing Address - Zip Code:43078-1013
Mailing Address - Country:US
Mailing Address - Phone:937-657-4069
Mailing Address - Fax:
Practice Address - Street 1:1505 GRIMES AVE
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:OH
Practice Address - Zip Code:43078-1013
Practice Address - Country:US
Practice Address - Phone:937-657-4069
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-01
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1102829251X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251X00000XAgenciesSupports Brokerage
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0398490Medicaid