Provider Demographics
NPI:1649694662
Name:CRENSHAW, KELLY L (PSYD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:L
Last Name:CRENSHAW
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 BELLWETHER WAY STE 240
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-2959
Mailing Address - Country:US
Mailing Address - Phone:360-588-2500
Mailing Address - Fax:360-785-2016
Practice Address - Street 1:12 BELLWETHER WAY STE 240
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-2959
Practice Address - Country:US
Practice Address - Phone:360-588-2500
Practice Address - Fax:360-785-2016
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-11
Last Update Date:2024-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY60885078103G00000X, 103TA0700X, 103TB0200X, 103TC0700X, 103G00000X
TX36685103TB0200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & AgingGroup - Multi-Specialty
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAPY60885078OtherDEPARTMENT OF HEALTH