Provider Demographics
NPI:1215994207
Name:CRENSHAW, BRADLEY JOHN (PHD)
Entity type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:JOHN
Last Name:CRENSHAW
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:20 MAPLEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:MA
Mailing Address - Zip Code:01002-1843
Mailing Address - Country:US
Mailing Address - Phone:413-549-4146
Mailing Address - Fax:
Practice Address - Street 1:79 S PLEASANT ST
Practice Address - Street 2:SUITE 6
Practice Address - City:AMHERST
Practice Address - State:MA
Practice Address - Zip Code:01002-2370
Practice Address - Country:US
Practice Address - Phone:413-259-1017
Practice Address - Fax:413-259-1017
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2008-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6679103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0526886Medicaid
MA24757OtherHEALTH NEW ENGLAND
MAW05830OtherBLUE CROSS/BLUE SHIELD
MA62000574OtherRAILROAD MEDICARE
MA24757OtherHEALTH NEW ENGLAND