Provider Demographics
NPI:1962188110
Name:CRISCO, ANDREW JAMES (PSYD)
Entity type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:JAMES
Last Name:CRISCO
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:185 44TH ST SW STE B
Mailing Address - Street 2:
Mailing Address - City:GRANDVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49418-3363
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:185 44TH ST SW STE B
Practice Address - Street 2:
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418-3363
Practice Address - Country:US
Practice Address - Phone:262-352-2742
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-23
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4098-57103TC0700X
MI6301019237103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical