Provider Demographics
NPI:1598363012
Name:CRAWFORD, DERRICK DEWAYNE
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:DEWAYNE
Last Name:CRAWFORD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4701 OLD HICKORY BLVD APT C202
Mailing Address - Street 2:
Mailing Address - City:OLD HICKORY
Mailing Address - State:TN
Mailing Address - Zip Code:37138-2073
Mailing Address - Country:US
Mailing Address - Phone:615-339-7583
Mailing Address - Fax:
Practice Address - Street 1:4701 OLD HICKORY BLVD APT C202
Practice Address - Street 2:
Practice Address - City:OLD HICKORY
Practice Address - State:TN
Practice Address - Zip Code:37138-2073
Practice Address - Country:US
Practice Address - Phone:615-339-7583
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-16
Last Update Date:2020-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN9309225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN9309OtherLICENSED MASSAGE THERAPIST