Provider Demographics
NPI:1215584289
Name:CRANDALL, STEPHANIE (LMSW)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:CRANDALL
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:
Other - Last Name:PETCHULAT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9550 WHITE OAK LN STE 200
Mailing Address - Street 2:
Mailing Address - City:JOHNSTON
Mailing Address - State:IA
Mailing Address - Zip Code:50131-2267
Mailing Address - Country:US
Mailing Address - Phone:515-259-8110
Mailing Address - Fax:
Practice Address - Street 1:9550 WHITE OAK LN STE 200
Practice Address - Street 2:
Practice Address - City:JOHNSTON
Practice Address - State:IA
Practice Address - Zip Code:50131-2267
Practice Address - Country:US
Practice Address - Phone:515-259-8110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-23
Last Update Date:2019-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA0967791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical