Provider Demographics
NPI:1497210066
Name:CRANDALL, AMY JANE ELIZABETH
Entity Type:Individual
Prefix:
First Name:AMY JANE
Middle Name:ELIZABETH
Last Name:CRANDALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13756 SW 143RD ST UNIT B
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186-7570
Mailing Address - Country:US
Mailing Address - Phone:812-870-1748
Mailing Address - Fax:
Practice Address - Street 1:9380 SW 72ND ST STE B246
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33173-5454
Practice Address - Country:US
Practice Address - Phone:812-870-1748
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-07
Last Update Date:2019-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY9913103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist