Provider Demographics
NPI:1639496656
Name:CRANDELL, KIMBERLEY ALIINA (MA)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLEY
Middle Name:ALIINA
Last Name:CRANDELL
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 WATERHOUSE ST
Mailing Address - Street 2:APT. 2
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02144-1716
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:32 WATERHOUSE ST
Practice Address - Street 2:APT. 2
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02144-1716
Practice Address - Country:US
Practice Address - Phone:617-910-6340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-30
Last Update Date:2010-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAS48114620103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst