Provider Demographics
NPI:1982971263
Name:CRENSHAW, MARY EMMA (LISW,LICDC)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:EMMA
Last Name:CRENSHAW
Suffix:
Gender:F
Credentials:LISW,LICDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5504 STATE RD
Mailing Address - Street 2:
Mailing Address - City:PARMA
Mailing Address - State:OH
Mailing Address - Zip Code:44134-2250
Mailing Address - Country:US
Mailing Address - Phone:216-773-2503
Mailing Address - Fax:
Practice Address - Street 1:5050 SOM CENTER RD APT 323-2
Practice Address - Street 2:
Practice Address - City:WILLOUGHBY
Practice Address - State:OH
Practice Address - Zip Code:44094-4278
Practice Address - Country:US
Practice Address - Phone:216-773-2503
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-30
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH976149101YA0400X
OH0600066106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist