Provider Demographics
NPI:1649510587
Name:CRANDALL, WADE ROLLIN
Entity type:Individual
Prefix:MR
First Name:WADE
Middle Name:ROLLIN
Last Name:CRANDALL
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:WADE
Other - Middle Name:ROLLIN
Other - Last Name:CRANDALL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPCC
Mailing Address - Street 1:1900 SILVER LAKE RD NW
Mailing Address - Street 2:
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112-1786
Mailing Address - Country:US
Mailing Address - Phone:651-628-9566
Mailing Address - Fax:651-628-0411
Practice Address - Street 1:3833 COON RAPIDS BLVD NW STE 120
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-2599
Practice Address - Country:US
Practice Address - Phone:763-767-3350
Practice Address - Fax:763-767-0912
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-28
Last Update Date:2019-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCC00541101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor