Provider Demographics
NPI:1831303536
Name:CRUEA, KRISTINE
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:
Last Name:CRUEA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KRISTINE
Other - Middle Name:
Other - Last Name:SIMPAO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:892 E CHICAGO ST STE H
Mailing Address - Street 2:
Mailing Address - City:COLDWATER
Mailing Address - State:MI
Mailing Address - Zip Code:49036-2063
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:892 E CHICAGO ST STE H
Practice Address - Street 2:
Practice Address - City:COLDWATER
Practice Address - State:MI
Practice Address - Zip Code:49036-2063
Practice Address - Country:US
Practice Address - Phone:517-278-9533
Practice Address - Fax:517-279-2756
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501012547225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5551012547OtherLICENSE#