Provider Demographics
NPI:1700118353
Name:CRENSHAW, ANNETTE MOCK
Entity Type:Individual
Prefix:
First Name:ANNETTE
Middle Name:MOCK
Last Name:CRENSHAW
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 1:215 JEP WHEELER RD
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-6501
Mailing Address - Country:US
Mailing Address - Phone:678-923-1088
Mailing Address - Fax:
Practice Address - Street 1:215 JEP WHEELER RD
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-6501
Practice Address - Country:US
Practice Address - Phone:678-923-1088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-08
Last Update Date:2010-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA720022501AMedicaid