Provider Demographics
NPI:1558934703
Name:FALLON-KRUEGER, MAUREEN LOUISE
Entity Type:Individual
Prefix:
First Name:MAUREEN
Middle Name:LOUISE
Last Name:FALLON-KRUEGER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:533 TOURNAMENT CIR
Mailing Address - Street 2:
Mailing Address - City:NORTON SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:49444-9786
Mailing Address - Country:US
Mailing Address - Phone:616-450-1570
Mailing Address - Fax:
Practice Address - Street 1:1401 CEDAR ST NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-1375
Practice Address - Country:US
Practice Address - Phone:616-391-5720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-23
Last Update Date:2021-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI520100894225XN1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XN1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistNeurorehabilitation