Provider Demographics
NPI:1104017672
Name:CRUZ, CAROLYN A (OTR)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:A
Last Name:CRUZ
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30901 PALMER RD
Mailing Address - Street 2:
Mailing Address - City:WESTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48186-9529
Mailing Address - Country:US
Mailing Address - Phone:734-367-8438
Mailing Address - Fax:
Practice Address - Street 1:30901 PALMER RD
Practice Address - Street 2:
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48186-9529
Practice Address - Country:US
Practice Address - Phone:734-367-8438
Practice Address - Fax:734-722-9524
Is Sole Proprietor?:No
Enumeration Date:2007-08-08
Last Update Date:2009-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201003054225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1508883299OtherWRPH
MI5201003054OtherMI LICENSE