Provider Demographics
NPI:1669496733
Name:CRANDALL, DAWN DANIELLE
Entity Type:Individual
Prefix:
First Name:DAWN
Middle Name:DANIELLE
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 1:3346 MEACHEM RD
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53405-4666
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:102 NORTH STATE STREET
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:WI
Practice Address - Zip Code:53167
Practice Address - Country:US
Practice Address - Phone:262-331-4397
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4088026225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI$$$$$$$$$007OtherBLUE CROSS BLUE SHIELD WI