Provider Demographics
NPI:1962974378
Name:CRUDUP, SHAWNTEA NICOLE (MA BCBA)
Entity type:Individual
Prefix:MRS
First Name:SHAWNTEA
Middle Name:NICOLE
Last Name:CRUDUP
Suffix:
Gender:F
Credentials:MA BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48 MARY ST
Mailing Address - Street 2:
Mailing Address - City:CHICOPEE
Mailing Address - State:MA
Mailing Address - Zip Code:01020-1110
Mailing Address - Country:US
Mailing Address - Phone:413-563-1432
Mailing Address - Fax:
Practice Address - Street 1:1 FEDERAL ST BLDG 101
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01105-1222
Practice Address - Country:US
Practice Address - Phone:603-689-5825
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-23
Last Update Date:2018-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1-18-33224103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst