Provider Demographics
NPI:1003514019
Name:CRANDALL, MACKENZIE MICHAEL (LLPC, MA, TLLP)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:MICHAEL
Last Name:CRANDALL
Suffix:
Gender:M
Credentials:LLPC, MA, TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2375 WALTON BLVD UNIT 4
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48309-1459
Mailing Address - Country:US
Mailing Address - Phone:248-200-8023
Mailing Address - Fax:
Practice Address - Street 1:5980 S MAIN ST STE 101
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346-2377
Practice Address - Country:US
Practice Address - Phone:248-625-2970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-20
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6451022802101Y00000X
MI6362009701103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling