Provider Demographics
NPI:1376222893
Name:CRANDALL, RAYMOND GLENN III (CO61176966)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:GLENN
Last Name:CRANDALL
Suffix:III
Gender:M
Credentials:CO61176966
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14819 E MISSION AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99216-1960
Mailing Address - Country:US
Mailing Address - Phone:206-566-2797
Mailing Address - Fax:
Practice Address - Street 1:14819 E MISSION AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99216-1960
Practice Address - Country:US
Practice Address - Phone:206-566-2797
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-12
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO61176966101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)