Provider Demographics
NPI:1174032411
Name:KRUSS, SIA
Entity Type:Individual
Prefix:
First Name:SIA
Middle Name:
Last Name:KRUSS
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 1:12425 NW BARNES RD APT 43
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-6091
Mailing Address - Country:US
Mailing Address - Phone:971-563-2629
Mailing Address - Fax:
Practice Address - Street 1:6010 SW SHATTUCK RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97221-1043
Practice Address - Country:US
Practice Address - Phone:503-246-8811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-28
Last Update Date:2017-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR391631225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist