Provider Demographics
NPI:1164175162
Name:CRANDLE, LAURA JEAN (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:JEAN
Last Name:CRANDLE
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11600 LAKESHORE DR
Mailing Address - Street 2:
Mailing Address - City:GRAND HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49417-9662
Mailing Address - Country:US
Mailing Address - Phone:616-291-1033
Mailing Address - Fax:
Practice Address - Street 1:445 104TH AVE
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-9107
Practice Address - Country:US
Practice Address - Phone:616-795-9693
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-31
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101005256235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist