Provider Demographics
NPI:1053557587
Name:CRUMLY, SALLY J (LCSW)
Entity type:Individual
Prefix:MS
First Name:SALLY
Middle Name:J
Last Name:CRUMLY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1954 HOWELL BRANCH RD
Mailing Address - Street 2:106
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32792-1041
Mailing Address - Country:US
Mailing Address - Phone:407-657-8555
Mailing Address - Fax:407-657-5774
Practice Address - Street 1:1954 HOWELL BRANCH RD
Practice Address - Street 2:106
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792-1041
Practice Address - Country:US
Practice Address - Phone:407-657-8555
Practice Address - Fax:407-657-5774
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-06
Last Update Date:2009-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW46721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL10745887OtherCAQH