Healthcare Provider Details

I. General information

NPI: 1558934703
Provider Name (Legal Business Name): MAUREEN LOUISE FALLON-KRUEGER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2021
Last Update Date: 07/23/2021
Certification Date: 07/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 CEDAR ST NE
GRAND RAPIDS MI
49503-1375
US

IV. Provider business mailing address

533 TOURNAMENT CIR
NORTON SHORES MI
49444-9786
US

V. Phone/Fax

Practice location:
  • Phone: 616-391-5720
  • Fax:
Mailing address:
  • Phone: 616-450-1570
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XN1300X
TaxonomyNeurorehabilitation Occupational Therapist
License Number520100894
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: