Provider Demographics
NPI:1578813077
Name:KRUTZ, SUSAN A (COTA)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:A
Last Name:KRUTZ
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3263 BURNING TREE LANE
Mailing Address - Street 2:
Mailing Address - City:ATTICA
Mailing Address - State:MI
Mailing Address - Zip Code:48412
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3263 BURNING TREE LANE
Practice Address - Street 2:
Practice Address - City:ATTICA
Practice Address - State:MI
Practice Address - Zip Code:48412
Practice Address - Country:US
Practice Address - Phone:810-417-3598
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-12
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5202007193314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility