Healthcare Provider Details

I. General information

NPI: 1700051901
Provider Name (Legal Business Name): REBECCA LEIGH CRANDALL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2008
Last Update Date: 04/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11611 SAN VICENTE BLVD SUITE 600
LOS ANGELES CA
90049-5106
US

IV. Provider business mailing address

11611 SAN VICENTE BLVD SUITE 600
LOS ANGELES CA
90049-5106
US

V. Phone/Fax

Practice location:
  • Phone: 310-284-3684
  • Fax:
Mailing address:
  • Phone: 310-284-3684
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084F0202X
TaxonomyForensic Psychiatry Physician
License NumberG077214
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberG077214
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: