Provider Demographics
NPI:1194569558
Name:CRAWFORD, BLONDENA HARRIS (SUDRC, NCCPS, CESP)
Entity type:Individual
Prefix:
First Name:BLONDENA
Middle Name:HARRIS
Last Name:CRAWFORD
Suffix:
Gender:F
Credentials:SUDRC, NCCPS, CESP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 VISTA CIR UNIT D
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27106-1987
Mailing Address - Country:US
Mailing Address - Phone:336-823-4730
Mailing Address - Fax:
Practice Address - Street 1:7235 SANTA MONICA BLVD
Practice Address - Street 2:
Practice Address - City:WEST HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90046-6724
Practice Address - Country:US
Practice Address - Phone:336-338-8065
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-20
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15258101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)