Basic Information
| Provider Information | |||||||||
| NPI: | 1487276523 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CRISPIN | ||||||||
| FirstName: | SHANA | ||||||||
| MiddleName: | JEN | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 850 POPLAR AVE BLDG 2 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381054607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9012875565 | ||||||||
| FaxNumber: | 9012876804 | ||||||||
| Practice Location | |||||||||
| Address1: | 51 N DUNLAP ST STE 400 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381054625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9012877337 | ||||||||
| FaxNumber: | 9012875506 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2020 | ||||||||
| LastUpdateDate: | 07/25/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 7229 | TN | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | 088587 | NY | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 7229 | TN | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.