Provider Demographics
NPI:1477814747
Name:CROSDALE, TANYA
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:
Last Name:CROSDALE
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 1:208 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29624-1600
Mailing Address - Country:US
Mailing Address - Phone:864-367-0949
Mailing Address - Fax:866-448-9303
Practice Address - Street 1:208 S MAIN ST
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29624-1600
Practice Address - Country:US
Practice Address - Phone:864-367-0949
Practice Address - Fax:866-448-9303
Is Sole Proprietor?:No
Enumeration Date:2012-06-04
Last Update Date:2013-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5408101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional