Provider Demographics
NPI:1386100402
Name:KRUCKENBERG, ELLISON M (COTA/L)
Entity type:Individual
Prefix:
First Name:ELLISON
Middle Name:M
Last Name:KRUCKENBERG
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9487 S WASATCH DOWNS CIR
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-9289
Mailing Address - Country:US
Mailing Address - Phone:385-226-9401
Mailing Address - Fax:
Practice Address - Street 1:401 S 400 E
Practice Address - Street 2:
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-4933
Practice Address - Country:US
Practice Address - Phone:801-295-2361
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-13
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12931092-4202224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Multi-Specialty