Provider Demographics
NPI:1780106179
Name:KRUSCAVAGE, COURTNEY JANE
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:JANE
Last Name:KRUSCAVAGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 STONEHOUSE BND
Mailing Address - Street 2:
Mailing Address - City:WILLOW STREET
Mailing Address - State:PA
Mailing Address - Zip Code:17584-7803
Mailing Address - Country:US
Mailing Address - Phone:843-780-1222
Mailing Address - Fax:
Practice Address - Street 1:51 PETERS RD
Practice Address - Street 2:
Practice Address - City:LITITZ
Practice Address - State:PA
Practice Address - Zip Code:17543-7685
Practice Address - Country:US
Practice Address - Phone:717-627-7575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-07
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA304268872255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer