Provider Demographics
NPI:1053569814
Name:CRUTCHER, TIFFANY JANYEE (DPT)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:JANYEE
Last Name:CRUTCHER
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:
Practice Address - Street 1:23915 W MAIN ST
Practice Address - Street 2:SUITE A
Practice Address - City:PLAINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60544-1967
Practice Address - Country:US
Practice Address - Phone:815-609-0570
Practice Address - Fax:815-609-1026
Is Sole Proprietor?:No
Enumeration Date:2008-09-05
Last Update Date:2010-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-016341225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$001Medicaid
IL202845095Medicare PIN
IL212608011Medicare PIN
IL$$$$$$$$$001Medicaid