Provider Demographics
NPI:1487255642
Name:CRUM, SIARRA GRACE
Entity type:Individual
Prefix:
First Name:SIARRA
Middle Name:GRACE
Last Name:CRUM
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 1:102 BELLWOOD LANE
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:PA
Mailing Address - Zip Code:15946-1441
Mailing Address - Country:US
Mailing Address - Phone:814-619-6120
Mailing Address - Fax:
Practice Address - Street 1:102 BELLWOOD LANE
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:PA
Practice Address - Zip Code:15946-1441
Practice Address - Country:US
Practice Address - Phone:814-619-6120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-04
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer