Provider Demographics
NPI:1407377443
Name:DEGRANDCHAMP, CRYSTAL MARIE (MA, LLPC)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:MARIE
Last Name:DEGRANDCHAMP
Suffix:
Gender:F
Credentials:MA, LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1370 N OAKLAND BLVD STE 105
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48327-1572
Mailing Address - Country:US
Mailing Address - Phone:248-666-8870
Mailing Address - Fax:248-666-5023
Practice Address - Street 1:1370 N. OAKLAND BLVD., SUITE 105
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48327
Practice Address - Country:US
Practice Address - Phone:248-666-8870
Practice Address - Fax:248-666-5023
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401017548101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional