Provider Demographics
NPI:1952730996
Name:CRENSHAW-CORLEY, ROSE M
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:M
Last Name:CRENSHAW-CORLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ROSE
Other - Middle Name:M
Other - Last Name:CRENSHAW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:45 LEHIGH AVE
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07112-2503
Mailing Address - Country:US
Mailing Address - Phone:973-923-3755
Mailing Address - Fax:973-923-3755
Practice Address - Street 1:45 LEHIGH AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07112-2503
Practice Address - Country:US
Practice Address - Phone:973-923-3755
Practice Address - Fax:973-923-3755
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-08
Last Update Date:2013-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SW04710500104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker