Provider Demographics
NPI:1801363320
Name:CRUDUP, ADRIENNE
Entity Type:Individual
Prefix:
First Name:ADRIENNE
Middle Name:
Last Name:CRUDUP
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 SAINT NICHOLAS TER APT 45
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10027-3542
Mailing Address - Country:US
Mailing Address - Phone:917-825-2054
Mailing Address - Fax:
Practice Address - Street 1:1 SAINT NICHOLAS TER APT 45
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10027-3542
Practice Address - Country:US
Practice Address - Phone:917-825-2054
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-01
Last Update Date:2018-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency