Provider Demographics
NPI:1801049119
Name:CRUSOE, WENDY R
Entity type:Individual
Prefix:
First Name:WENDY
Middle Name:R
Last Name:CRUSOE
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 1:900 AUBURN AVE
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48342-3300
Mailing Address - Country:US
Mailing Address - Phone:248-333-3335
Mailing Address - Fax:248-333-7133
Practice Address - Street 1:900 AUBURN AVE
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48342-3300
Practice Address - Country:US
Practice Address - Phone:248-333-3335
Practice Address - Fax:248-333-7133
Is Sole Proprietor?:No
Enumeration Date:2008-10-30
Last Update Date:2008-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501004738225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist