Healthcare Provider Details

I. General information

NPI: 1033436969
Provider Name (Legal Business Name): CRANDELL W BLISS L.C.P.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2010
Last Update Date: 12/02/2025
Certification Date: 12/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1590 S MILWAUKEE AVE STE 315
LIBERTYVILLE IL
60048-3786
US

IV. Provider business mailing address

1590 S MILWAUKEE AVE STE 315
LIBERTYVILLE IL
60048-3786
US

V. Phone/Fax

Practice location:
  • Phone: 847-566-2500
  • Fax:
Mailing address:
  • Phone: 847-566-2500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180004080
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: