Provider Demographics
NPI:1114390564
Name:KRUMM, GUSTAVE
Entity Type:Individual
Prefix:
First Name:GUSTAVE
Middle Name:
Last Name:KRUMM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 160862
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95816-0862
Mailing Address - Country:US
Mailing Address - Phone:916-806-0286
Mailing Address - Fax:
Practice Address - Street 1:1550 JULIESSE AVE
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95815-1803
Practice Address - Country:US
Practice Address - Phone:916-921-6598
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-06
Last Update Date:2015-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAK0509301006101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA11721179OtherKAISER PERMANENTE