Provider Demographics
NPI:1629313887
Name:CRUM, EDWARD R (LICDC)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:R
Last Name:CRUM
Suffix:
Gender:M
Credentials:LICDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2317 E HOME RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45503-2520
Mailing Address - Country:US
Mailing Address - Phone:937-342-4379
Mailing Address - Fax:
Practice Address - Street 1:2317 E HOME RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45503-2520
Practice Address - Country:US
Practice Address - Phone:937-342-4379
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-29
Last Update Date:2021-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH131007101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0370792Medicaid