Provider Demographics
NPI:1962266825
Name:KRUIT, MADISSEN ELIVIA
Entity type:Individual
Prefix:
First Name:MADISSEN
Middle Name:ELIVIA
Last Name:KRUIT
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 1:1860 N 95TH LN STE 105
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85037-4333
Mailing Address - Country:US
Mailing Address - Phone:623-907-0828
Mailing Address - Fax:623-907-3058
Practice Address - Street 1:1860 N 95TH LN STE 105
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85037-4333
Practice Address - Country:US
Practice Address - Phone:623-907-0828
Practice Address - Fax:623-907-3058
Is Sole Proprietor?:No
Enumeration Date:2024-02-12
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist