Provider Demographics
NPI:1285362707
Name:CRANDELL, TANISHA ALEXIS
Entity type:Individual
Prefix:
First Name:TANISHA
Middle Name:ALEXIS
Last Name:CRANDELL
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 1:730 GEORGE ST APT 112
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-5225
Mailing Address - Country:US
Mailing Address - Phone:203-909-4957
Mailing Address - Fax:
Practice Address - Street 1:93 EDWARDS ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-3933
Practice Address - Country:US
Practice Address - Phone:203-772-1270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-11
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker