Provider Demographics
NPI:1376294728
Name:CROWFIELD-WHITE, ELISHA
Entity type:Individual
Prefix:
First Name:ELISHA
Middle Name:
Last Name:CROWFIELD-WHITE
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 1:1315 COPLIN ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48215-2787
Mailing Address - Country:US
Mailing Address - Phone:313-686-9528
Mailing Address - Fax:
Practice Address - Street 1:1315 COPLIN ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48215-2787
Practice Address - Country:US
Practice Address - Phone:313-686-9528
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-17
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703129876164W00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
C614209603716OtherC614209603716