Provider Demographics
NPI:1093983173
Name:PHELAN, KRYSANDRA LYNN (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:KRYSANDRA
Middle Name:LYNN
Last Name:PHELAN
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:MISS
Other - First Name:KRYSANDRA
Other - Middle Name:LYNN
Other - Last Name:GREWE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:9844 DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:IRA
Mailing Address - State:MI
Mailing Address - Zip Code:48023-2813
Mailing Address - Country:US
Mailing Address - Phone:810-434-6371
Mailing Address - Fax:
Practice Address - Street 1:9844 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:IRA
Practice Address - State:MI
Practice Address - Zip Code:48023-2813
Practice Address - Country:US
Practice Address - Phone:810-434-6371
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-12
Last Update Date:2012-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801089204104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1093983173Medicaid