Provider Demographics
NPI:1508849126
Name:TEDROW, CRYSTAL JEAN (AAS)
Entity Type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:JEAN
Last Name:TEDROW
Suffix:
Gender:F
Credentials:AAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1070 OLD NATIONAL PIKE
Mailing Address - Street 2:
Mailing Address - City:FREDERICKTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15333-2114
Mailing Address - Country:US
Mailing Address - Phone:724-632-6801
Mailing Address - Fax:
Practice Address - Street 1:1152 WOOD ST
Practice Address - Street 2:
Practice Address - City:CALIFORNIA
Practice Address - State:PA
Practice Address - Zip Code:15419-1260
Practice Address - Country:US
Practice Address - Phone:724-938-2099
Practice Address - Fax:724-938-3221
Is Sole Proprietor?:No
Enumeration Date:2005-11-29
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007288440098Medicaid
PA328834D024298OtherVALUE BEHAVIORAL HEALTH