Basic Information
| Provider Information | |||||||||
| NPI: | 1003173451 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KRUSEMARK | ||||||||
| FirstName: | MARIA | ||||||||
| MiddleName: | S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 66 MILO PECK LN | ||||||||
| Address2: | |||||||||
| City: | WINDSOR | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060951807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9283087671 | ||||||||
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| Practice Location | |||||||||
| Address1: | 55 COOPER ST | ||||||||
| Address2: | |||||||||
| City: | AGAWAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 010012149 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4137868000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2012 | ||||||||
| LastUpdateDate: | 04/23/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 8079 | MA | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | 4435 | CT | N | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.