Basic Information
| Provider Information | |||||||||
| NPI: | 1649510587 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CRANDALL | ||||||||
| FirstName: | WADE | ||||||||
| MiddleName: | ROLLIN | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CRANDALL | ||||||||
| OtherFirstName: | WADE | ||||||||
| OtherMiddleName: | ROLLIN | ||||||||
| OtherNamePrefix: | MR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LPCC | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1900 SILVER LAKE RD NW | ||||||||
| Address2: | |||||||||
| City: | NEW BRIGHTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551121786 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6516289566 | ||||||||
| FaxNumber: | 6516280411 | ||||||||
| Practice Location | |||||||||
| Address1: | 3833 COON RAPIDS BLVD NW STE 120 | ||||||||
| Address2: | |||||||||
| City: | COON RAPIDS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554332599 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7637673350 | ||||||||
| FaxNumber: | 7637670912 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2013 | ||||||||
| LastUpdateDate: | 02/07/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | CC00541 | MN | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.