Provider Demographics
NPI:1003654195
Name:CRAWFORD, SHAWNTAY DORAE
Entity type:Individual
Prefix:
First Name:SHAWNTAY
Middle Name:DORAE
Last Name:CRAWFORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHAWNTAY
Other - Middle Name:DORAE
Other - Last Name:BROADNAX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:971 E WICHITA AVE
Mailing Address - Street 2:
Mailing Address - City:RUSSELL
Mailing Address - State:KS
Mailing Address - Zip Code:67665-2444
Mailing Address - Country:US
Mailing Address - Phone:785-377-4744
Mailing Address - Fax:
Practice Address - Street 1:215 E 4TH ST
Practice Address - Street 2:
Practice Address - City:HOISINGTON
Practice Address - State:KS
Practice Address - Zip Code:67544-2317
Practice Address - Country:US
Practice Address - Phone:620-292-7168
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-15
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst