Provider Demographics
NPI:1922146232
Name:KRUCKER, ELISABETH MARIE (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ELISABETH
Middle Name:MARIE
Last Name:KRUCKER
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 W BRUCE AVE
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85233-5422
Mailing Address - Country:US
Mailing Address - Phone:602-616-3144
Mailing Address - Fax:
Practice Address - Street 1:303 W BRUCE AVE
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85233-5422
Practice Address - Country:US
Practice Address - Phone:602-616-3144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP2155235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ746563Medicaid