Provider Demographics
NPI:1417718529
Name:CRUSE, ANNETTE
Entity Type:Individual
Prefix:
First Name:ANNETTE
Middle Name:
Last Name:CRUSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ANNIE
Other - Middle Name:
Other - Last Name:CRUSE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:103 CORPORATE LAKE DR STE B
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-7290
Mailing Address - Country:US
Mailing Address - Phone:573-415-2444
Mailing Address - Fax:
Practice Address - Street 1:103 CORPORATE LAKE DR STE B
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-7290
Practice Address - Country:US
Practice Address - Phone:573-413-2444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-17
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014002861224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant