Provider Demographics
NPI:1194437947
Name:CRAWFORD, CHARLENE
Entity type:Individual
Prefix:
First Name:CHARLENE
Middle Name:
Last Name:CRAWFORD
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 1:308 STRINGER DR
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42501-1665
Mailing Address - Country:US
Mailing Address - Phone:606-219-0856
Mailing Address - Fax:
Practice Address - Street 1:1340 S HIGHWAY 27 STE C
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42501-2900
Practice Address - Country:US
Practice Address - Phone:606-219-0856
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-22
Last Update Date:2022-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251B00000X
KY324500000X, 251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility