Provider Demographics
NPI:1780200154
Name:CRAWFORD, SHASTA JOY (PT)
Entity Type:Individual
Prefix:
First Name:SHASTA
Middle Name:JOY
Last Name:CRAWFORD
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:SHASTA
Other - Middle Name:JOY
Other - Last Name:FLEMING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2835 CHILDRESS DR
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:CA
Mailing Address - Zip Code:96007-3563
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2835 CHILDRESS DR
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:CA
Practice Address - Zip Code:96007-3563
Practice Address - Country:US
Practice Address - Phone:530-378-0998
Practice Address - Fax:530-378-2072
Is Sole Proprietor?:No
Enumeration Date:2020-06-22
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR63683225100000X
CA301186225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist