Provider Demographics
NPI:1356356265
Name:CRAGWALL & ASSOCIATES P.C.
Entity type:Organization
Organization Name:CRAGWALL & ASSOCIATES P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:JOAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:STOFFER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-940-3331
Mailing Address - Street 1:4469 CASCADE ROAD SE
Mailing Address - Street 2:SUITE 4469
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-3632
Mailing Address - Country:US
Mailing Address - Phone:616-940-3331
Mailing Address - Fax:616-940-1377
Practice Address - Street 1:4469 CASCADE RD SE
Practice Address - Street 2:SUITE 4469
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-3632
Practice Address - Country:US
Practice Address - Phone:616-940-3331
Practice Address - Fax:616-940-1377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-29
Last Update Date:2008-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010113901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0D16218Medicare PIN