Provider Demographics
NPI:1588424824
Name:CRUMP, GAVIN CHANCELOR (LMT, OMT)
Entity type:Individual
Prefix:
First Name:GAVIN
Middle Name:CHANCELOR
Last Name:CRUMP
Suffix:
Gender:M
Credentials:LMT, OMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4400 NE PARVIN RD
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64117-2354
Mailing Address - Country:US
Mailing Address - Phone:816-582-7933
Mailing Address - Fax:
Practice Address - Street 1:5401 COLLEGE BLVD STE 212
Practice Address - Street 2:
Practice Address - City:LEAWOOD
Practice Address - State:KS
Practice Address - Zip Code:66211-1617
Practice Address - Country:US
Practice Address - Phone:816-582-7933
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-21
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS2023-013225700000X
MO2020029660225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist