Provider Demographics
NPI:1225804289
Name:CRANDALL, TRACY LYNN (PT)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:LYNN
Last Name:CRANDALL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5437 133RD AVE
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:MI
Mailing Address - Zip Code:49419-9622
Mailing Address - Country:US
Mailing Address - Phone:616-848-4280
Mailing Address - Fax:
Practice Address - Street 1:9 E 8TH ST
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-3501
Practice Address - Country:US
Practice Address - Phone:616-796-3800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-30
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501010028225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist