Provider Demographics
NPI:1427506237
Name:CRENSHAW, LYDIA (CERT HAIR LOSS SPEC)
Entity type:Individual
Prefix:MRS
First Name:LYDIA
Middle Name:
Last Name:CRENSHAW
Suffix:
Gender:F
Credentials:CERT HAIR LOSS SPEC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1070 IRIS DR SW
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30094-5901
Mailing Address - Country:US
Mailing Address - Phone:678-670-1787
Mailing Address - Fax:
Practice Address - Street 1:55 HEATON PLACE TRL
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30016-0215
Practice Address - Country:US
Practice Address - Phone:678-670-1787
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-21
Last Update Date:2016-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACO0904651744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management