Healthcare Provider Details

I. General information

NPI: 1376222893
Provider Name (Legal Business Name): RAYMOND GLENN CRANDALL III CP61656010
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2023
Last Update Date: 08/21/2025
Certification Date: 08/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14819 E MISSION AVE
SPOKANE VALLEY WA
99216-1960
US

IV. Provider business mailing address

14819 E MISSION AVE
SPOKANE VALLEY WA
99216-1960
US

V. Phone/Fax

Practice location:
  • Phone: 206-566-2797
  • Fax:
Mailing address:
  • Phone: 206-566-2797
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCO61176966
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCG61689414
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: