Provider Demographics
NPI:1174674188
Name:DECALUWE, KRISTEN MICHELLE (PTA)
Entity Type:Individual
Prefix:MRS
First Name:KRISTEN
Middle Name:MICHELLE
Last Name:DECALUWE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31700 VAN DYKE AVE STE 160
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-7952
Mailing Address - Country:US
Mailing Address - Phone:586-276-8001
Mailing Address - Fax:586-276-8002
Practice Address - Street 1:31700 VAN DYKE AVE STE 160
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-7952
Practice Address - Country:US
Practice Address - Phone:586-276-8001
Practice Address - Fax:586-276-8002
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI230195Medicare ID - Type UnspecifiedPROVIDER NUMBER