Provider Demographics
NPI:1841637394
Name:CRUMP, CAROLYN DENISE
Entity type:Individual
Prefix:MISS
First Name:CAROLYN
Middle Name:DENISE
Last Name:CRUMP
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 1:1636 MARATHON DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89108-2726
Mailing Address - Country:US
Mailing Address - Phone:702-633-5305
Mailing Address - Fax:
Practice Address - Street 1:1636 MARTHON DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89108
Practice Address - Country:US
Practice Address - Phone:702-633-5305
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-23
Last Update Date:2013-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV461291354Medicaid