Provider Demographics
NPI:1316111404
Name:CRANDALL-BASS, LAURIE LOUISE (MA)
Entity type:Individual
Prefix:MS
First Name:LAURIE
Middle Name:LOUISE
Last Name:CRANDALL-BASS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3424 NE BRYCE ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212
Mailing Address - Country:US
Mailing Address - Phone:503-544-4402
Mailing Address - Fax:
Practice Address - Street 1:2410 SE 121ST AVE
Practice Address - Street 2:#216
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216-4066
Practice Address - Country:US
Practice Address - Phone:503-544-4402
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-18
Last Update Date:2009-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health