Basic Information
| Provider Information | |||||||||
| NPI: | 1407377443 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEGRANDCHAMP | ||||||||
| FirstName: | CRYSTAL | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | MA, LLPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1370 N OAKLAND BLVD STE 105 | ||||||||
| Address2: | |||||||||
| City: | WATERFORD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483271572 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2486668870 | ||||||||
| FaxNumber: | 2486665023 | ||||||||
| Practice Location | |||||||||
| Address1: | 1370 N. OAKLAND BLVD., SUITE 105 | ||||||||
| Address2: | |||||||||
| City: | WATERFORD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2486668870 | ||||||||
| FaxNumber: | 2486665023 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2017 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 6401017548 | MI | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.