Provider Demographics
NPI:1396497210
Name:OWEN-CRUISE, DAVID WELLINGTON (LLP)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:WELLINGTON
Last Name:OWEN-CRUISE
Suffix:
Gender:M
Credentials:LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3135 S STATE ST STE 108
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108-1653
Mailing Address - Country:US
Mailing Address - Phone:734-369-3180
Mailing Address - Fax:
Practice Address - Street 1:3135 S STATE ST STE 108
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48108-1653
Practice Address - Country:US
Practice Address - Phone:734-369-3180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-21
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6361004328103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical