Provider Demographics
NPI:1952795049
Name:KRUCHTEN, MARY SUE
Entity type:Individual
Prefix:
First Name:MARY SUE
Middle Name:
Last Name:KRUCHTEN
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 1:329 WESTPORT DR
Mailing Address - Street 2:
Mailing Address - City:PINGREE GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60140-9162
Mailing Address - Country:US
Mailing Address - Phone:847-460-7934
Mailing Address - Fax:
Practice Address - Street 1:329 WESTPORT DR
Practice Address - Street 2:
Practice Address - City:PINGREE GROVE
Practice Address - State:IL
Practice Address - Zip Code:60140-9162
Practice Address - Country:US
Practice Address - Phone:847-460-8934
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-26
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist