Provider Demographics
NPI:1669825543
Name:CRUM, AMY
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:CRUM
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 1:3187 TANSY TRL SW
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49418-9153
Mailing Address - Country:US
Mailing Address - Phone:616-481-1100
Mailing Address - Fax:
Practice Address - Street 1:5570 WILSON AVE SW
Practice Address - Street 2:SUITE L
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49418-8867
Practice Address - Country:US
Practice Address - Phone:616-481-1100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-15
Last Update Date:2016-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501009359225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist