Provider Demographics
NPI:1336134022
Name:CRUTCHFIELD, BRONWYNN W (MED, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:BRONWYNN
Middle Name:W
Last Name:CRUTCHFIELD
Suffix:
Gender:F
Credentials:MED, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2199 MOUNT ZION RD
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30236-2525
Mailing Address - Country:US
Mailing Address - Phone:770-478-0025
Mailing Address - Fax:770-478-0087
Practice Address - Street 1:2199 MOUNT ZION RD
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30236-2525
Practice Address - Country:US
Practice Address - Phone:770-478-0025
Practice Address - Fax:770-478-0087
Is Sole Proprietor?:No
Enumeration Date:2005-09-19
Last Update Date:2009-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP004875235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000894693AMedicaid