Provider Demographics
NPI:1518412493
Name:CRUM, EMILY NICOLE (MA, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:EMILY
Middle Name:NICOLE
Last Name:CRUM
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1441 S FENBROOK LN
Mailing Address - Street 2:SUITE D
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-4176
Mailing Address - Country:US
Mailing Address - Phone:646-298-5246
Mailing Address - Fax:
Practice Address - Street 1:1441 S FENBROOK LN
Practice Address - Street 2:SUITE D
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-4176
Practice Address - Country:US
Practice Address - Phone:646-298-5246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-19
Last Update Date:2016-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22004854A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist