Provider Demographics
NPI:1861410888
Name:CRENSHAW, MARY CHRISTINE (PHD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:CHRISTINE
Last Name:CRENSHAW
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:
Other - Last Name:CRENSHAW
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:PO BOX 162
Mailing Address - Street 2:
Mailing Address - City:THETFORD CENTER
Mailing Address - State:VT
Mailing Address - Zip Code:05075-0162
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11 BEAVER MEADOW RD
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:VT
Practice Address - Zip Code:05055-9305
Practice Address - Country:US
Practice Address - Phone:802-649-2260
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2011-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT71955103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical