Provider Demographics
NPI:1184884710
Name:CRUTCHER, BRENDA GAIL (PTA)
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:GAIL
Last Name:CRUTCHER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12490 N WELDON RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61102-9640
Mailing Address - Country:US
Mailing Address - Phone:815-289-6325
Mailing Address - Fax:
Practice Address - Street 1:12490 N WELDON RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61102-9640
Practice Address - Country:US
Practice Address - Phone:815-289-6325
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-17
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160003860225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant