Provider Demographics
NPI:1730443391
Name:CRUTHIS, KACI
Entity type:Individual
Prefix:
First Name:KACI
Middle Name:
Last Name:CRUTHIS
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 1:9515 HOLY CROSS LN
Mailing Address - Street 2:
Mailing Address - City:BREESE
Mailing Address - State:IL
Mailing Address - Zip Code:62230-3618
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9515 HOLY CROSS LN
Practice Address - Street 2:
Practice Address - City:BREESE
Practice Address - State:IL
Practice Address - Zip Code:62230-3618
Practice Address - Country:US
Practice Address - Phone:618-526-5436
Practice Address - Fax:618-526-2826
Is Sole Proprietor?:No
Enumeration Date:2012-06-28
Last Update Date:2012-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.016063225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist