Provider Demographics
NPI:1124027891
Name:CRUTCHER, DENISE ANNETTE (PT)
Entity Type:Individual
Prefix:MRS
First Name:DENISE
Middle Name:ANNETTE
Last Name:CRUTCHER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MRS
Other - First Name:DENISE
Other - Middle Name:ANNETTE
Other - Last Name:KORNEMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:604 E MAIN ST STE E
Mailing Address - Street 2:
Mailing Address - City:MAHOMET
Mailing Address - State:IL
Mailing Address - Zip Code:61853-3544
Mailing Address - Country:US
Mailing Address - Phone:217-366-1323
Mailing Address - Fax:
Practice Address - Street 1:604 E MAIN ST STE E
Practice Address - Street 2:
Practice Address - City:MAHOMET
Practice Address - State:IL
Practice Address - Zip Code:61853-3544
Practice Address - Country:US
Practice Address - Phone:217-366-1323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-15
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070011685225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL94012Medicare ID - Type Unspecified