Provider Demographics
NPI:1417036377
Name:CRENSHAW, DAVID HOWARD (LPT)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:HOWARD
Last Name:CRENSHAW
Suffix:
Gender:M
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 LANDMARK DR
Mailing Address - Street 2:STE E3
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-6165
Mailing Address - Country:US
Mailing Address - Phone:309-467-3220
Mailing Address - Fax:309-467-3240
Practice Address - Street 1:120 N MAIN STREET
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:IL
Practice Address - Zip Code:61530-1182
Practice Address - Country:US
Practice Address - Phone:309-467-3220
Practice Address - Fax:309-467-3240
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.004852225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL10232007OtherBLUE CROSS BLUE SHIELD
ILQ19402Medicare UPIN
IL209434Medicare ID - Type UnspecifiedMEDICARE NO.