Provider Demographics
NPI:1508175597
Name:CRANDALL, JULIE ANN
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:ANN
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 1:1650 N HILTON ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-1734
Mailing Address - Country:US
Mailing Address - Phone:406-230-1971
Mailing Address - Fax:
Practice Address - Street 1:1650 N HILTON ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-1734
Practice Address - Country:US
Practice Address - Phone:406-230-1971
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-24
Last Update Date:2013-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTSLP-SP-LIC-3085235Z00000X
IDSLP-2176235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist