Basic Information
| Provider Information | |||||||||
| NPI: | 1124534508 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CRANDALL | ||||||||
| FirstName: | HOLLY | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | LADC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2360 N BROADWAY | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | MN | ||||||||
| PostalCode: | 559064065 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5072820142 | ||||||||
| FaxNumber: | 5072826261 | ||||||||
| Practice Location | |||||||||
| Address1: | 2360 NORTH BROADWAY | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5072820142 | ||||||||
| FaxNumber: | 5072826261 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2017 | ||||||||
| LastUpdateDate: | 12/20/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TA0400X | 304375 | MN | Y | Behavioral Health & Social Service Providers | Psychologist | Addiction (Substance Use Disorder) |
No ID Information.