Provider Demographics
NPI:1164295622
Name:CRUTCHER, MAKENZIE PAIGE (DPT)
Entity Type:Individual
Prefix:
First Name:MAKENZIE
Middle Name:PAIGE
Last Name:CRUTCHER
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6399 GOODMAN RD STE 108
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-7063
Mailing Address - Country:US
Mailing Address - Phone:662-892-8339
Mailing Address - Fax:662-892-8396
Practice Address - Street 1:6399 GOODMAN RD STE 108
Practice Address - Street 2:
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654-7063
Practice Address - Country:US
Practice Address - Phone:662-892-8339
Practice Address - Fax:662-892-8396
Is Sole Proprietor?:No
Enumeration Date:2023-11-06
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT7634225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist