Provider Demographics
NPI:1902045909
Name:CRUTCHER, SERETTA ARSTACIA (MT)
Entity Type:Individual
Prefix:MS
First Name:SERETTA
Middle Name:ARSTACIA
Last Name:CRUTCHER
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5133
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30154-0003
Mailing Address - Country:US
Mailing Address - Phone:404-428-9043
Mailing Address - Fax:
Practice Address - Street 1:870 CRESTMARK DR
Practice Address - Street 2:SUITE 103
Practice Address - City:LITHIA SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30122-2665
Practice Address - Country:US
Practice Address - Phone:404-428-9043
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-13
Last Update Date:2009-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT004500225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist